>J^    ^^A 


/     THE      ^ 
O    LIBRARIES  ^ 


HEALTH 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/industrialmediciOOmock 


INDUSTRIAL  MEDICINE 
AND  SURGERY> 


BY 

HARRY  E.  MOCK,  B.S.,  M.D.,  F.A.C.S. 

Assistant  Professor  qi'Ihdustrial  Medicine  and  Surgery  at  Rush  Medical 
College;  Attending  Surgeon,  St.  Luke's  Hospital;  Visiting  Surgeon  to 
Washington  Boulevard  Hospital;  Chief  Surgeon  to  Sears,  Roebuck  & 
Company;  Fellow  Institute  of  Medicine,  Chicago;  Lieutenant-Colonel, 
Medical  Corps,  U.  S.  A. 


WITH  210  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1919 


m9 


Copyright,  iqiq,  by  W.  B.  Saunders  Company 


.      PRINTED     IN     AMERICA 

PRESS     OF 

W.    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


To 

MARY  MINERVA  JACKSON  MOCK 

and 

GOLDA  TAYLOR  MOCK 

MY  MOTHER 

and 

MY  WIFE 

This  book  is  affectionately  dedicated. 


PREFACE 


In  presenting  this  book  to  the  medical  profession,  and  to  those 
laymen  interested  in  the  subject,  I  am  quite  conscious  of  the  fact  that 
it  is  a  deviation  from  the  usual  character  of  a  text-book  on  medicine 
or  surgery.  Instead  of  dealing  with  the  pathology,  diagnosis  and 
treatment  of  specific  diseases  or  the  individualistic  practice  of  medicine, 
I  have  endeavored  to  sat  forth  the  reasons  for,  and  the  methods  of 
a  form  of  group  medicine  which  has  stood  the  test  of  years,  and  proven 
its  practicability  in  many  of  the  large  industries  of  the  country. 

The  conservation  of  the  lives  and  limbs  of  the  working  people 
and  the  reclamation  of  those  disabled  in  the  daily  strife  have  become 
a  definite  program  in  the  industrial  world.  The  humanizing  influence 
of  this  work  has  caused  many  an  employer  to  consider  other  means 
of  contributing  to  the  health,  comfort  and  contentment  of  his  working 
force.  Wherever  these  principles  have  been  adopted,  the  industry 
has  been  rewarded  by  greater  efficiency  among  its  employees,  with 
a  corresponding  increase  in  production. 

With  the  growth  of  this  form  of  medicine  the  field  has  extended 
into  the  living  and  home  conditions  of  the  working  forces,  gradually 
resulting  in  closer  co-operation  with  the  public  health  authorities. 
In  fact,  it  has  become  a  vital  factor  in  public  health.  To-day  the 
achievements  of  industrial  medicine  and  surgery  are  one  of  the 
strongest  arguments  in  favor  of  a  national  health  program. 

It  is  less  than  ten  years  since  the  majority  of  leaders  in  our  pro- 
fession could  see  naught  but  a  questionable  future,  a  sort  of  lowering 
of  the  prescribed  standards,  for  those  physicians  who  entered  the 
field  of  the  company  doctor.  To  the  pioneers  in  this  new  specialty, 
however,  it  seemed  that  these  industries  offered  a  veritable  human 
laboratory  where  the  constant  supervision  of  the  health  of  thousands 
of  employees  would  enable  the  development  of  a  real  system  of  pre- 
ventive medicine  and  preventive  surgery.  It  was  their  first  glimpse 
of  group  medicine,  a  form  of  practice  radically  different  from  that 
taught  in  the  medical  colleges  and  learned  during  the  one  or  two  years 
of  hospital  interneship  following  graduation. 

The  comprehensive  systems  of  industrial  medicine  and  surgery 
established  in  many  industries  to-day  were  the  result  of  a  gradual  devel- 
opment. The  glimpse  grew  into  a  vision — the  vision  broadened  with 
each  subsequent  year.     No  one  man  nor  no  one  establishment  can 

7 


8  PREFACE 

claim  the  honor  of  creating  this  work,  for  a  number  of  concerns 
throughout  the  country  engaged  competent  physicians  and  surgeons 
who  simultaneously  developed  these  new  principles  in  medicine. 

The  community  of  purpose  drew  together  these  physicians.  By 
frequent  consultations,  exchange  of  ideas  and  experiences,  and  by  the 
comparison  of  results,  the  vision  of  each  individual  broadened  and 
the  scope  of  the  work  expanded.  It  would  be  extremely  remiss  on 
my  part  to  refrain  from  acknowledging  with  sincere  gratitude  the 
great  assistance  which  I  have  received  from  many  of  the  leaders, 
both  medical  and  lay,  in  this  work.  Because  of  our  close  association, 
I  am  especially  indebted  to  Drs.  Otto  Geier,  C.  W.  Schereschewsky, 
Francis  Patterson,  W.  Irving  Clark,  C.  W.  Farnum,  Wilbur  Post, 
Thomas  Crowder,  C.  D.  Selby,  A.  M.  Harvey,  and  James  Britton. 

During  a  period  of  nine  years  as  chief  surgeon  of  one  of  the  largest 
industries  of  Chicago,  I  kept  careful  notes  of  the  development  of  this 
form  of  medical  practice  as  well  as  complete  records  of  the  results 
obtained.  For  the  last  two  years  of  that  period  I  taught  this  new 
specialty  to  the  students  at  Rush  Medical  College,  where  a  night 
clinic  on  Industrial  Medicine  and  Surgery  was  established.  This 
afforded  an  excellent  opportunity  to  study  conditions  in  other  indus- 
tries lacking  adequate  health  services.  I  am  greatly  indebted  to  my 
associates  in  this  college  work  and  especially  to  Dr.  John  Ellis,  Dr. 
John  Dodson,  Dean  of  Push  Medical  College,  and  Mr.  John  E.  Ransom, 
Superintendent  of  the  Central  Free  Dispensary. 

This  book  endeavors  to  present  these  various  experiences.  It  is 
based  upon  the  practical  application  of  every  principle  herein  de- 
tailed not  only  in  this  one  industry  but  in  many  of  the  other  large 
concerns  of  the  country.  With  the  growth  of  this  work  of  human 
maintenance  in  industry,  it  is  becoming  more  and  more  apparent 
that  our  medical  schools  must  correlate  these  broad  social  and  eco- 
nomic principles  with  their  teaching  of  medicine.  Therefore,  while  it 
will  be  of  value  to  those  physicians  engaged  in  industrial  practice,  it 
is  felt  that  such  a  book  will  be  especially  valuable  to  the  coming  genera- 
tion of  medical  students.  As  far  as  possible  highly  technical  language 
has  been  avoided  in  order  to  extend  its  usefulness  to  the  layman — to 
those  employers,  industrial  engineers,  social  workers,  and  labor  leaders 
who  are  honestly  striving  to  improve  the  condition  of  those  who  must 
produce  and  provide. 

To  those  pioneer  industries  having  the  foresight  to  establish  and 
stimulate  the  growth  of  a  genuine  health  service  among  their  employees, 
the  world  is  everlastingly  indebted.  Physicians  working  in  this  field 
could  have  made  little  progress  without  the  moral  and  financial  back- 
ing of  these  employers.     No  one  realizes  this  better  than  the  author. 


PREFACE  9 

The  opportunity  of  publicly  acknowledging  this  fact  cannot  be  re- 
sisted. For  all  that  has  been  accomplished  in  their  medical  depart- 
ment, the  greatest  credit  must  be  given  to  the  present  management 
of  Sears,  Roebuck  &  Company. 

To  the  ten  doctors  and  twelve  nurses  on  their  medical  staff,  I 
wish  to  express  my  deepest  gratitude  for  their  loyalty  and  co-opera- 
tion during  these  years  of  serving  together.  I  am  especially  grateful 
to  Dr.  Edward  A.  Oliver,  my  associate  for  seven  years,  and  to  Miss 
May  Middleton,  the  Superintendent  of  nurses,  both  of  whom  have 
rendered  invaluable  assistance. 

A  number  of  my  colleagues  in  other  industries  have  been  unusually 
generous  in  furnishing  data  and  other  material  and  every  effort  has 
been  made  to  properly  accredit  these  and  all  other  references. 

To  the  publishers  and  those  others  who  have  so  willingly  co-operated 
in  the  preparation  of  this  book,  I  will  always  be  exceedingly  grateful. 

Harry  E.  Mock. 

122  S.  Michigan  Ave., 
Chicago,  III., 
August,  1919. 


CONTENTS 
PART  I 

INDUSTRIAL  HEALTH  SERVICE 

CHAPTER  I 

Page 

Health  Supervision 1' 

CHAPTER  II 
The  Plant  Hospital  or  Doctor's  Office 33 

CHAPTER  III 
The  Medical  Staff 43 

CHAPTER  IV 
The  Nurse  in  Industry •• 51 

CHAPTER  V 
Employees  Dental  Service 60 

CHAPTER  VI 
A  Practical  System  OF  Industrial  Medicine  AND  Surgery .      67 

CHAPTER  VII 
Benefits  and  Profits  of  the  Medical  Department .      79 

CHAPTER  VIII 
Cost  of  the  Medical  Department •     90 

CHAPTER  IX 
Supervision  of  the  Health  of  the  Managerial  Staff 98 

CHAPTER  X 

Recreation  and  Exercise  as  Related  to  Supervision  of  Health  of  Em- 


ployees  

CHAPTER  XI 


102 


Food 10^ 

11 


12  CONTENTS 

CHAPTER  XII 

Page 

Records .   116 

CHAPTER  XIII 
Industrial  HiJalth  Service 125 


PART  II 

PREVENTION 

CHAPTER  XIV 
Preventive  Medicine  and  Preventive  Surgery  in  Industries 133 

CHAPTER  XV 

Industrial  Hygiene:  A  General  Outline  of  the  Problems 141 

CHAPTER  XVI 
Industrial  Hygiene:  Specific  Problems 151 

CHAPTER  XVII 
Industrial  Hygiene  and  Production 167 

CHAPTER  XVIII 
Epidemiology  in  Industry 178 

CHAPTER  XIX 
Health  Hazards  in  Occupations 201 

CHAPTER  XX 
The  National  Safety  Council .    .    .    .   310 

CHAPTER  XXI 
Accident  Prevention 318 

CHAPTER  XXII 
The  Spirit  of  Prevention 335 

CHAPTER  XXIII 
The  Influence  of  New  Employees  and  "Speeding-up"  on  Accident  Rate  351 


CONTENTS  13 

PART  III 

INDUSTRIAL  MEDICINE 
CHAPTER  XXIV 

Page 
Medical,  Examination  of  Employees 355 

CHAPTER  XXV 

Medical  Examination  of  Applicants  for  Work 370 

CHAPTER  XXVI 
Examination    and    Correction  of   Eye  Conditions 386 

CHAPTER  XXVII 
Medical  Treatment  of  Employees 391 

CHAPTER  XXVIII 
Women  in  Industry 405 

CHAPTER  XXIX 
The  Tuberculous  Employee 429 

CHAPTER  XXX 

Reclaiming  the  Tuberculous  Soldiers  from  the  Military  and  Industrial 

Armies 461 

PART  IV 
INDUSTRIAL  SURGERY 

CHAPTER  XXXI 

The  Surgical  Dispensary,  Staff  and  Equipment;  Preventive  Surgery     475 

CHAPTER  XXXII 
First  Aid 492 

CHAPTER  XXXin 
Emergency  Surgery    .....   511 

CHAPTER  XXXIV 
The  Subsequent  or  Permanent  Treatment  of  Certain  Injuries.    .    .    .   542 


14  CONTENTS 

CHAPTER  XXXV 

Page 
X-RAY  IN  Industrial  Surgery 568 

CHAPTER  XXXVI 
Hand  Infections 574 

CHAPTER  XXXVII 
Fractures  .....    598 

CHAPTER  XXXVIII 

Open  Treatment  of  Fractures 629 

CHAPTER  XXXIX 
Amputations 639 

CHAPTER  XL 
The  Employees  Foot 657 


PART  V 

COMPENSATION.    INSURANCE.    MEDICOLEGAL  PHASES 

CHAPTER  XLI 

Employees'  Compensation  from  the  Medical  Viewpoint  .......   667 

CHAPTER  XLII 

Compensable  Hernia 690 

CHAPTER  XLIII 

The  Coincidence  of  Accidents  with  Disease  ............   707 

CHAPTER  XLIV 

Other  Traumatisms  with  Medicolegal  Aspects  ...    i    ......    .   719 

CHAPTER  XLV 
Health  Insurance  .,..,...   740 

CHAPTER  XLVI 

Employees'  Mutual  Benefit  Associations.    .............   760 


CONTENTS  15 

PART  VI 

RECONSTRUCTION 

CHAPTER  XLVII 

Page 

AiMBRICANIZATION   OF  THE    FOREIGN  EMPLOYEE 769 

CHAPTER  XLVIII 
Human  Conservation  and  Reclamation  of  the  Disabled.    ......   776 

Bibliography 801 

Index    ...............................   825 


INDUSTRIAL  MEDICINE 
AND  SURGERY 


Part  I 
INDUSTRIAL  HEALTH  SERVICE 


CHAPTER  I 
HEALTH    SUPERVISION 
EMPLOYEES'  SERVICE  DEPARTMENTS 

Industrial  medicine  and  surgery,  the  new  specialty,  deals  with  the 
human  maintenance  problem  in  mdustry.  Our  modern  mdustrial 
concerns  have  regularly  employed  experts  to  study  their  expensive, 
comphcated  machines  in  order  to  preserve  their  mechanism  and  obtain 
their  maximum  efficiency.  The  human  machine  alone  has  been 
neglected. 

It  is  true  that  company  surgeons  have  existed  for  many  years  but 
rarely  did  the  scope  of  their  work  extend  beyond  the  repair  of  injuries. 
This  new  specialty  in  medicine  not  only  furnishes  adequate  medical 
and  surgical  care  when  necessary,  but  includes  all  measures  bearing 
upon  the  health,  welfare  and  working  ability  of  employees. 

Supervision  of  Health  of  Employees  has  become  an  essential 
part  of  the  organization  of  many  large  mdustries.  The  past  decade 
has  witnessed  the  birth,  in  this  country,  of  this  one  of  the  most  im- 
portant of  human  conservation  movements,  and  the  last  four  years 
have  seen  it  expand  into  a  great,  five  issue  with  far-reaching  influence. 
Since  its  birth,  many  other  issues  offering  service  to  the  great  mass  of 
wage-earners  have  been  created.  Chief  among  these  are  the  Mutual 
Benefit  Associations,  the  Safety  Movement,  and  Employees'  Compensa- 
tion Acts.  The  latter  still  is  an  ugly  child  in  many  respects,  but  gives 
promise  of  a  great  future.  Its  brothers,  Employees'  Health  Insurance, 
Old  Age  Insurance  and  Insurance  against  Non-employment  have  not 
as  yet  been  born,  but  this  new  specialty  is  rapidly  demonstrating 
their  need. 

2  17 


18 


INDUSTRIAL   MEDICINE    AND    SURGERY 


A  comprehensive  system  of  the  supervision  of  the  health  of  em- 
ployees must  include  every  branch  of  preventive  medicine  and  surgery 
and  of  remedial  medicine  and  surgery,  as  well  as  industrial  hygiene  and 
sanitation.  These  are  primarily  medical  functions  and  must  be  ad- 
ministered by  the  medical  department  of  an  industry. 

Many  other  activities  have  been  developed  in  our  best  organized 
industries,  however,  which  have  a  direct  bearing  on  the  comfort, 
convenience,  and  state  of  mind  of  the  employees,  and  therefore  have 
the  closest  relationship  to  health  supervision.  Recognition  of  this 
fact  has  caused  the  creation  of  Employees'  Service  Departments  in 
several  concerns. 

or  HEALTH  or  EMPLOYES   OP 
MAINTENANCE  DEPART. 


SUPO 
HUMAN 


CEIiTRAL 
MAffAGSR 


EneiNEER 


CMPLOrfS 


yismm 

NURSe3 


Fig.   1. — A  successful  plan  of  organization  in  one  industry. 

Usually  a  broad-visioned  business  man,  or  occasionally  a  trained 
sociologist,  has  been  placed  at  the  head  of  such  a  department.  It  is 
his  duty  to  co-ordinate  all  these  activities  so  that  the  greatest  service 
will  be  given  to  the  employees.  The  actual  work  of  the  medical 
department  is  under  the  doctor,  the  safety  work  is  under  the  safety 
engineer,  the  employment  manager  attends  to  employment.  In  other 
words,  the  functions  of  these  various  services  are  decentralized  as  to 
activities  but  are  centralized  under  one  head  as  to  policy,  adminis- 
tration, etc.  (Fig.  1). 

In  at  least  three  large  concerns  all  these  functions  have  been 
placed  directly  under  the  supervision  of  the  chief  of  the  medical  staff. 
The  argument  in  favor  of  this  is  that  the  broadly  trained  physician, 
with  a  proper  economic  and  social  sense,  because  of  his  close  relation- 
ship to  the  employees,  is  the  best  manager  for  such  a  department. 


HEALTH    SUPERVISION  19 

Time  alone  will  prove  which  is  the  best  plan.  The  tendency  to 
give  more  and  more  power  to  the  medical  director  is  growing,  and 
certainly  demonstrates  that  all  things  which  increase  the  health  of 
employees  must  increase  dividends  to  the  employer.  It  also  demon- 
strates that  the  vision  of  the  physician  in  industry  must  constantly 
expand,  and  he  must  become  fully  cognizant  of  those  activities  which 
can  well  be  called  the  adjuncts  to  health  supervision. 

This  fact  is  positive,  namely,  all  activities  which  deal  directly  with 
the  health  and  safety  of  the  employees  should  be  placed  under  the 
medical  director,  and  those  functions  which  look  to  the  comfort  and 
welfare  of  the  employees,  although  administered  by  various  lay 
managers,  must  be  closely  co-ordinated  with,  and  often  supervised  by 
the  health  department.  In  fact,  everything  about  the  industry  which 
in  any  way  touches  the  health  problem  should  be  subject  to  the  ap- 
proval or  criticism  of  the  medical  staff  if  the  greatest  benefits  from 
such  a  system  are  to  be  obtained. 

What  are  the  activities  of  an  Employees'  Service  Department? 
From  a  medical  standpoint  they  can  be  divided  into  those  services 
which  deal  directly  with  health  supervision,  and  those  which  are 
adjuncts  to  health  supervision,  as  follows: 

1.  Health  Supervision  of  Employees : 
(a)  Medical  Service. 

(6)  Surgical  Service. 

(c)  Dental  Service. 

(d)  Nursing  Service. 

(e)  Safety  Service. 

(/)  Sanitation  Service. 

2.  Adjuncts  to  Health  Supervision: 
(a)  Employment  Service. 

(6)  Restaurant  Service. 

(c)  Recreation  Service. 

(d)  Welfare  Service. 

(e)  Insurance  Service. 

(/)  Banking  and  Loan  Service. 

(g)  Housing  and  Community  Service. 

To  the  internist,  surgeon,  or  the  regular  family  physician,  it  is 
quite  evident  that  this  new  type  of  physician,  working  in  industry,  is 
confronted  with  many  problems  which  have  not  been  included  in  the 
usual  medical  curriculum.  Let  me  assure  you,  however,  that  all 
these  services  in  the  working  homes  of  your  patients  have  a  decided 
bearing  on  their  health.  Recognition  of  the  relationship  between 
conditions  in  industry  and  the  health  of  the  people  will  become  more 
and  more  essential  in  the  teaching  of  medicine  in  the  future. 


20  INDUSTRIAL   MEDICINE    AND    SURGERY 

Details  of  this  work — the  general  principles,  the  purposes  and  the 
results  of  all  the  functions  of  industrial  medicine  and  surgery,  will  be 
given  in  subsequent  chapters.  This  discussion  will  be  limited  to 
outhning  the  scope  of  health  supervision.  I  want  to  emphasize  that 
the  plan  of  supervision  which  I  am  about  to  offer  is  the  ideal  for  which 
all  company  surgeons  should  strive — an  ideal  to  which  no  industrial 
concern  as  yet  has  fully  attained. 

The  prevention  of  sickness,  accidents  and  inefficiency  among 
employees  is  the  purpose  of  all  forms  of  health  supervision.  A  general 
survey  of  the  component  parts  is  the  first  step  in  prevention,  be  it 
prevention  of  fires,  accidents,  burglaries,  war,  flood,  or  what  not. 
Thus,  the  first  step  should  be  a  general  survey  of  the  working  place; 
the  mechanical  appliances  therein;  the  employees,  individually  and 
in  a  group;  and  even  the  employers  and  their  attitude  and  state  of 
mind  toward  supervision  of  health.  The  physician  entering  an 
industry  where  this  work  has  not  been  in  vogue  will  usually  have  to 
develop  this  proper  mental  attitude  on  the  part  of  both  the  employer 
and  the  employed. 

MEDICAL  SERVICE 

The  medical  service  in  a  properly  conducted  health  supervision 
plan,  includes  those  activities  dealing  directly  with  the  equation 
of  health  in  the  employees  and  the  treatment  of  their  diseased 
conditions. 

One  of  the  first  requirements  in  the  general  survey  of  this  field  is 
the  complete  physical  examination  of  every  employee,  and,  when 
practicable,  a  periodical  re-examination  of  these  employees,  approx- 
imately every  six  months.  I  qualify  the  re-examinations,  because, 
whereas  in  a  plant  employing  only  a  few  hundred  people  this  can  be 
done  with  a  very  small  medical  staff,  in  one  employing  ten  or  fifteen 
thousand  people  it  would  take  a  staff  of  four  doctors  doing  nothing 
else  to  re-examine  the  force  every  six  months.  Such  a  plan  would 
interfere  with  the  work  of  the  employees  to  the  extent  that  few  man- 
agements would  consent  to  this  unusual  precaution. 

The  medical  examination  should  be  complete  in  every  case,  both 
male  and  female.  The  history  in  each  case  can  be  obtained  by  a 
trained  nurse,  who  can  also  take  the  temperature,  pulse,  height  and 
weight  of  the  employee  before  he  is  sent  in  to  the  doctor.  The  phys- 
ical examination  can  be  made  while  a  qualified  laboratory  assistant 
is  analyzing  the  urine,  the  specimen  being  obtained  just  before  the  em- 
ployee is  sent  to  the  examining  room.  Next,  the  dentist  and  the 
nose-thro at-and-eye  specialist  examine  the  individual  in  turn. 

Provided  plenty  of  office  space  is  available  and  sufficient  and 
efficient  assistance  is  given,  this  examination  can  be  completed  in  25 


HEALTH    SUPERVISION  21 

minutes.  This  includes  the  time  necessary  for  disrobing  and  dressing 
again,  and  the  short  wait  for  his  turn.  Unless  some  condition  is  found 
which  requires  careful  study,  this  examination  need  not  take  over 
ten  minutes  of  any  of  the  doctors'  or  nurses'  time  before  whom  the 
employee  appears  for  each  step  in  his  examination. 

Many  times  a  day  individual  cases  will  present  themselves  which 
require  considerably  more  of  the  doctor's  time;  for  instance, 
certain  diseased  conditions  must  be  carefully  explained;  advice  appli- 
cable to  each  case  must  be  given;  the  doctor  must  ascertain  if  the 
proper  hne  of  treatment  is  being  followed  in  a  certain  case,  and,  if  not, 
must  arrange  for  it;  questions  must  be  taken  up  with  the  employees' 
manager  pertaining  to  change  of  work,  etc.;  matters  of  personal  hygiene 
must  be  discussed;  and  numerous  other  factors  deaUng  with  the  per- 
sonal equation  between  the  doctor  and  the  employee  must  be  met 
and  carefully  considered.  In  no  instance  should  this  medical  super- 
vision attain  such  a  high  plane  of  efficiency,  as  regards  speed  and  the 
number  of  employees  examined  per  day,  as  to  lose  sight  of  this  personal 
element — the  benefit  of  the  personal  contact  of  the  employees  with  the 
doctor. 

Many  company  physicians  may  object  to  such  a  thorough  physical 
examination  of  employees  as  is  here  outlined,  but,  remember,  this 
plan  is  based  upon  the  assumption  that  the  industry  wants  the  same 
efficiency  in  its  human  maintenance  department  which  it  demands  in 
all  other  departments,  and  efficiency  means  thoroughness.  The 
inspection  of  employees  and  choosing  only  those  for  physical  examina- 
tion who  seem  below  par  is  better  than  no  medical  supervision;  the 
physical  examinations  usually  made  on  girls,  namely,  the  head,  neck 
and  chest,  have  given  wonderful  results  in  supervising  the  health  of 
these  female  employees,  but  to  obtain  the  maximum  of  results  a 
complete  survey  of  the  entire  body  of  each  individual  is  necessary 
in  order  not  to  overlook  anything  which  might  be  detrimental  to 
health. 

The  pxirpose  of  a  complete  physical  survey  must  not  be  to  ehminate 
the  unfit  from  the  working  force,  but  must  be  done  absolutely  from 
the  standpoint  of  supervising  the  health  of  the  entire  group.  Thus,  it 
is  essential  to  ascertain  the  condition  of  health  of  each  individual  to 
discover  diseases  in  the  earliest  stages,  while  still  curable ;  to  find  any- 
one suffering  from  a  communicable  contagious  disease,  and  to  seek 
out  the  employee  chronically  diseased  yet  still  able  to  work  and  re- 
commend for  him  a  position  where  he  can  be  efficient  without 
hastening  the  course  of  his  disease. 

Until  such  time  as  the  State  takes  up  its  burden,  employers  should 
make  adequate  provision  to  render  proper  medical  care  and  sufficient 
financial  aid  to  him  who  is  forced  to  stop  work  because  of  this  system 


22  INDUSTRIAL   MEDICINE    AND    SURGERY 

of  supervision;  otherwise,  the  very  purpose  of  such  a  system  will  be 
defeated,  namely,  the  restoration  to  health  in  the  shortest  time  possible. 
Lack  of  money  and  the  worry  over  debts  are  great  drawbacks  to  the 
regaining  of  health. 

Of  equal  importance  with  the  medical  examination  and  re-examina- 
tion of  the  old  working  force  is  the  thorough  examination  of  every 
applicant  for  work;  in  fact,  this  is  just  as  essential  as  keeping  the  work- 
ing place  sanitary  when  once  you  have  removed  all  unsanitary  con- 
ditions. The  examinations  of  applicants,  however,  should  not  be 
made  for  the  purpose  of  choosing  only  the  strongest,  healthiest 
workers,  but  to  protect  the  old  working  force  from  any  applicant 
who  might  have  some  contagious  disease.  An  excellent  means  is  also 
given  for  supervision  of  the  health  of  these  prospective  employees  by 
preventing  those  with  serious  diseased  conditions  from  going  to  work, 
for  their  own  protection;  and  by  choosing  the  proper  type  of  work 
for  those  with  chronic  diseases  which  do  not  totally  unfit  them  for 
employment. 

I  have  talked  with  two  national  labor  officials,  and  they  assure  me 
that,  if  all  industries  would  approach  this  procedure  from  as  humane  a 
standpoint,  as  above  outhned,  they  would  thoroughly  endorse  the 
plan. 

Medical  treatment  of  diseased  employees  is  still  a  mooted  question. 

The  treatment  of  conditions  directly  the  result  of  occupations,  for 
which  the  employer  is  considered  responsible,  is  almost  universally 
recognized  as  a  logical  part  of  the  work  of  the  company  surgeon ;  but 
the  care  of  the  workman  injured  outside  the  plant,  or  whose  sickness 
has  no  connection  with  his  work  rightfully  belongs  in  the  opinion  of 
many  to  the  family  physician.  To  give  the  best  results  to  both  em- 
ployees and  employer,  complete  remedial  measures  must  go  hand  in 
hand  with  the  work  of  investigation  and  supervision. 

This  medical  and  surgical  treatment  has  already  been  instituted  in 
a  few  industries,  and  the  results  are  proving  its  worth.  Most  medical 
staffs  furnish  complete  surgical  care  to  those  injured  while  at  work  and 
the  more  rapid  recoveries,  fewer  permanent  disabilities,  and  lower 
death  rate  furnish  the  strongest  arguments  in  favor  of  such  a  plan. 
Every  company  surgeon  has  seen  the  most  deplorable  surgical  treat- 
ment given  to  workmen  injured  while  at  home.  Many  of  these  home 
accident  cases  are  neglected  by  the  employee  himself  until  some  severe 
infection  or  other  complication  finally  forces  him  to  consult  his  family 
doctor.  Even  then,  many  family  doctors,  untrained  in  emergency 
surgery,  will  give  inadequate  treatment,  for  example,  making  a  small 
incision  in  an  infected  area  when  a  wide-open  incision  is  indicated. 
As  a  result,  the  disability  of  the  outside  accident  case  is  often  pro- 
longed and  frequently  a  permanent  deformity  occurs  which  could 


HEALTH    SUPERVISION  23 

have  been  prevented  by  the  prompt,  early  treatment  of  the  accident 
by  the  surgical  mechanism  of  the  industry.  Many  surgeons  are 
daily  interfering  in  the  care  of  some  home  accident  case  in  order  to 
prevent  these  dire  results. 

Almost  the  same  situation  exists  in  the  medical  cases.  When 
a  diseased  condition  is  found,  the  employee  is  advised  as  to  the  best  line 
of  treatment  and  then  is  referred  to  his  family  physician.  Often  he 
receives  the  very  best  of  care  from  the  latter,  again  only  mediocre 
care,  and  occasionally  he  neglects  to  follow  the  advice  to  consult  his 
doctor,  waiting  until  the  condition  becomes  so  serious  that  he  is  forced 
to  do  so.  In  many  instances  the  case  is  treated  without  any  effort  at  a 
diagnosis  being  made.  Time  and  again  a  blood  examination  or  a 
stomach  analysis  would  show  the  true  state  of  affairs  and  would 
indicate  the  proper  line  of  treatment,  whereas  the  employee  is  taking 
pills  from  a  "bhnd  doctor,"  or  is  receiving  electrical  treatment  from 
a  quack. 

Daily  the  medical  staffs  of  industries  are  interfering  in  the  treat- 
ment of  sick  employees.  They  are  operating  more  and  more  on 
employees  who  have  some  surgical  condition,  when  careful  inquiry 
shows  that  they  cannot  afford  to  obtain  proper  surgical  and  hospital 
care,  or  when  it  is  apparent  that  the  condition  is  being  neglected  by 
the  family  physician. 

A  few  industries  have  assumed  the  care  of  all  cases  of  tuberculosis 
found  among  their  workmen.  Most  of  these  are  sent  to  sanatoria. 
Some  refuse  this  care  and  choose  home  treatment  under  the  family 
physician.  A  comparison  of  the  results  between  this  home  treatment 
and  sanatorium  treatment  proves  that  these  concerns  have  saved 
Hves  by  taking  complete  charge  of  the  tuberculous  employees. 

Some  industrial  medical  staffs  are  now  treating  all  syphilitic  and 
gonorrheal  cases,  with  the  result  that  scientific  care  is  curing  the  early 
cases,  and,  best  of  ?il,  society  is  protected.  The  old  plan  of  firing  the 
venereals  and  leaving  many  of  them  to  the  mercy  of  the  quack  is  no 
longer  practiced. 

Those  with  defective  vision  are  now  being  cared  for  by  competent 
ophthalmologists,  instead  of  allowing  the  employee  to  go  to  the  corner 
optician  for  their  glasses.  In  1915  the  writer  found  799  cases  of  defect- 
ive vision,  and  cared  for  179  of  these,  the  remainder  going  without 
care  or  to  whomsoever  they  saw  fit.  In  1916  he  found  1014  cases  of 
defective  vision  and  corrected  930.  Supervision  of  these  shows  that 
they  have  remained  corrected,  and  the  increased  efficiency  resulting 
therefrom  has  far  more  than  paid  for  the  cost  of  this  service. 

These  examples  therefore  prove  that,  hand  in  hand  with  the  super- 
vision of  the  health  of  employees,  there  must  be  proper  medical  and 
surgical    treatment   rendered — the    two    are    almost    inseparable.     I 


24  INDUSTRIAL    MEDICINE    AND    SURGERY 

do  not  mean  to  insinuate  that  the  medical  men  of  an  industry  are 
better  physicians  than  the  average  family  physician,  but  I  do  know- 
that  systematic  care  by  a  unit  of  medical  men,  each  trained  especially 
in  some  particular  line,  will  give  the  surest,  quickest  and  best  results. 

NURSING  SERVICE 

One  of  the  chief  aids  in  the  supervision  of  the  health  of  employ- 
ees is  a  well-trained  staff  of  industrial  nurses.  Special  training  is 
necessary  before  any  nurse  can  learn  all  the  ramifications  of  the  work 
of  an  industrial  nurse.  Through  her  the  employers  can  show  their 
friendly  interest  in  the  force.  The  small  merchant,  with  five  or  six 
employees,  can  personally  visit  and  offer  aid  to  one  of  his  men  when 
the  latter  is  sick  or  in  trouble;  but  the  large  employer,  with  several 
thousand  workmen,  must  depend  upon  some  other  agency  in  order 
to  show  his  friendly  interest  in  their  welfare. 

Thus,  every  industry  should  have  a  sufficient  number  of  these 
nurses  to  visit  each  sick  employee;  to  render  nursing  aid  when 
necessary;  to  report  on  his  condition  and  whether  or  not  he  is  receiving 
proper  medical  care.  She  also  diplomatically  ascertains  whether  or 
not  financial  aid  is  needed;  if  the  sick  one  is  worrying  over  accumu- 
lating debts;  if  the  home  environments  and  housing  conditions  are 
such  as  to  interfere  in  his  rapid  recovery;  in  fact,  she  is  able  to 
supervise  the  health  of  the  employee,  to  a  certain  extent,  while  at 
home. 

SURGICAL  SERVICE 

The  Surgical  Service  is  one  of  the  most  vital  branches  of  the  med- 
ical department.  The  company  surgeon,  working  in  the  front  Line 
trench  of  industry,  is  in  the  strategic  position  to  develop  the  most 
comprehensive  system  of  preventive  surgery.  His  first  duty  is  to 
study  and  enforce  every  possible  form  of  accident  prevention.  In 
the  minor  accidents,  such  as  pin-pricks,  bruises,  and  the  like,  which 
are  almost  unavoidable,  he  must  devise  means  of  preventing  comphca- 
tions  such  as  infections.  When  an  accident  occurs  he  must  be  close 
at  hand  to  render  the  earliest  possible  treatment,  and  must  continue 
to  treat  the  case  from  the  standpoint  of  preventing  undue  loss  of 
time  from  work,  preventing  permanent  disability,  and,  above  all,  to 
prevent  the  death  of  the  patient.  The  restoring  of  the  most  perfect 
function  in  an  injured  member  must  be  his  aim.  Such  a  surgeon  is 
constantly  striving  for  the  best  economic-end  result,  as  well  as  for  a 
medical-end  result. 

Every  industry  should  have  on  its  medical  staff  a  surgeon  com- 
petent to  handle  every  type  of  surgical  condition.     Even  where  a 


HEALTH    SUPERVISION  25 

specialist  is  required  for  certain  operations  this  company  surgeon  should 
continue  to  supervise  the  treatment.  Employees  sent  to  a  hospital 
for  surgical  care  usually  receive  more  prompt  attention  and  more 
careful  after-treatment  from  the  surgeon  who  is  directly  responsible 
to  the  management  of  an  industry.  Many  an  employee  has  been 
referred  to  one  of  the  large  hospitals  in  a  city  for  operation  when  his 
occupation  was  not  responsible  for  the  condition.  Often  three  or  four 
days  elapse  before  the  hospital  surgeon  finds  time  to  operate,  except,  of 
course,  in  very  acute  conditions.  After  the  operation  the  treatment 
is  left  largely  to  the  interne.  Unfortunately,  many  internes  have  not 
yet  developed  the  proper  social  sense,  or  do  not  consider  the  great 
economic  loss  due  to  keeping  the  patient  in  the  hospital  longer  than 
is  necessary.  These  employees  leave  the  hospital  dissatisfied  with 
the  treatment  which  they  have  received.  Their  statements  are  often 
exaggerated,  but  nevertheless  it  is  apparent  to  the  management  that 
the  cases  cared  for  by  the  company  surgeon  are  expedited,  while  too 
often  those  referred  to  the  general  staff  of  a  hospital  sustain  an  un- 
necessary loss  of  time.  This  condition  is  resulting  in  the  company 
surgeon  being  requested  by  the  management  to  operate  more  and  more 
often  on  workmen  with  conditions  other  than  injuries,  especially  when 
the  early  return  of  a  man  to  his  work  is  vital  to  the  production  of  the 
plant. 

In  many  industries  the  workmen  are  so  scattered  that  it  is  often  im- 
possible for  the  surgeon  to  render  prompt  treatment  when  an  accident 
occurs.  In  this  case  he  must  arrange  for  proper  first-aid  treatment  by 
some  competent  fellow-employee.  First-aid  stations  in  some  plants 
have  been  established  at  regular  intervals  throughout  the  buildings 
with  trained  laymen  in  charge  to  render  first-aid  to  every  injured 
employee.  In  others  three  or  four  intelligent  employees  are  chosen  in 
each  department  and  are  carefully  drilled  in  every  form  of  first-aid 
treatment  by  the  company  surgeon.  When  an  accident  occurs  in  that 
department  these  men  take  charge  of  the  case  and  render  the  early 
treatment  indicated.  This  first-aid  work,  however,  should  never  re- 
place the  doctor.  Practically  every  injury,  no  matter  how  slight, 
should  be  sent  or  taken  to  the  central  office  at  once  where  a  competent 
surgeon  can  take  charge.  In  many  places  this  first-aid  service  has 
been  developed  to  such  a  high  degree  that  it  is  one  of  the  most  impor- 
tant features  in  their  plans  for  health  supervision. 

SAFETY  SERVICE 

No  system  of  supervision  of  health  of  employees  is  complete  imless 
suitable  provision  is  made  for  the  prevention  of  accidents.  Therefore, 
a  safety  engineer  is  essential  in  making  the  general  survey  of  mechan- 


26  INDUSTRIAL    MEDICINE    AND    SURGERY 

ical  conditions  of  the  working  place  and  in  adding  every  appliance 
known  for  protection.  After  this  is  done  he  must  make  daily  inspec- 
tions of  the  plant  to  see  that  these  safeguards  against  accidents  are 
used  by  the  employees.  He  must  also  investigate  every  accident  in 
order  to  devise  some  means  to  prevent  its  recurrence. 

There  must  be  the  closest  co-operation  between  the  safety  engi- 
neer and  the  company  surgeon;  in  fact,  he  should  be  directly  con- 
nected with  the  medical  department.  The  surgeon  must  report 
every  accident  promptly  with  all  data  pertaining  to  its  cause  which  he 
obtains  from  the  injured  employee.  By  talking  freely  with  an  in- 
jured man  during  the  period  of  caring  for  him  the  doctor  can  learn 
many  apparently  insignificant  facts,  even  from  the  most  ignorant 
employee,  which  are  invaluable  in  this  work  of  prevention.  Like- 
wise, the  company  surgeon  is  the  safety  engineer  as  regards  the  human 
mechanism.  By  thoroughly  examining  the  injured  man  he  often 
finds  some  physical  or  mental  defect  as  the  cause  for  the  accident. 

SANITATION  SERVICE 

Sanitary  conditions  of  the  plant  have  a  very  definite  bearing  on 
the  comfort  and  health  of  the  employees.  Industrial  engineers  are  con- 
stantly pointing  to  the  relationship  between  industrial  sanitation  and 
maximum  production.  There  is  no  doubt  but  what  unsanitary  condi- 
tions about  a  plant  cause  more  sickness,  more  discontent  among 
the  employees,  greater  labor  turn-over,  and  a  very  definite  slowing 
up  of  production.  From  a  medical  standpoint  the  sanitary  inspec- 
tions are  almost  of  equal  importance  as  the  inspections  of  the 
force  by  physical  examinations.  The  medical  staff  should  see  that 
every  unsanitary  condition  is  removed  and  the  plant  is  made  as 
healthful  and  comfortable  as  possible.  To  accomplish  this  the  clean- 
liness of  the  building,  the  ventilation,  the  lighting,  the  temperature 
and  humidity,  the  disinfection  of  toilets  and  cuspidors,  the  installa- 
tion of  proper  washing  and  bathing  facilities,  the  removal  of  dangerous 
gases  and  dusts  and  the  fumigation  of  departments  or  rooms  where 
contagious  cases  have  developed  must  be  made  perfect  and  kept  so 
by  frequent  inspections. 

EMPLOYMENT  SERVICE 

The  question  may  well  be  asked  by  those  unfamiliar  with  this  work, 
why  the  employment  service  should  be  included  as  an  adjunct  to 
health  supervision.  The  very  fact  that  some  employment  managers 
in  certain  industries  are  endeavoring  to  have  the  medical  departments 
placed  under  them  demonstrates  that  there  must  be  a  very  definite 


HEALTH   SUPERVISION  27 

connection  between  health  and  employment.  But  the  employment 
problem  is  only  a  small  portion  of  the  health  program  in  any  industry, 
and  it  is  bound  to  curtail  the  work  of  the  medical  department  if  it  is 
made  subordinate  to  the  employment  department.  As  a  means  of 
health  supervision  it  would  be  more  logical  to  place  employment 
under  the  medical  director.  The  majority  of  concerns,  however,  con- 
sider it  best  to  have  the  closest  co-operation  between  these  two  depart- 
ments, but  to  have  them  operate  under  separate  heads. 

Every  applicant  for  work  should  be  thoroughly  examined  by  the 
medical  staff  in  order  to  prevent  the  introduction  of  contagious  diseases 
into,  the  plant  and  to  provide  for  the  proper  selection  of  work  for 
every  man  according  to  his  physical  and  mental  qualifications.  The 
employment  department  should  see  that  the  recommendation  of  the 
doctor  as  to  the  type  of  work  a  man  is  qualified  for  is  carefully 
followed. 

In  many  concerns  the  employees  are  no  longer  subject  to  the  whims 
of  the  foreman.  The  studies  in  labor  turn-over  have  revealed  the 
fact  that  the  employing  and  training  of  a  man  to  the  point  where  he  is 
efficient  is  too  expensive  a  proposition  to  warrant  his  careless  dis- 
charge unless  there  is  a  very  good  reason.  In  most  of  these  concerns 
no  employee  is  discharged  without  the  approval  of  the  employment 
manager.  The  latter  ascertains  why  the  man  has  not  made  good  on 
his  job,  and  sees  if  there  is  any  other  position  in  the  plant  in  which  he 
could  make  good.  The  medical  department  has  become  one  of  the 
most  important  allies  in  these  efforts  to  conserve  man-power.  Fre- 
quently some  incompatibility  between  the  occupation  and  the  physical 
condition  of  the  employee  is  responsible  for  his  failure  to  succeed  in  a 
given  position. 

The  earliest  impressions  the  new  employee  receives  concerning 
his  future  working  home  are  received  in  the  employment  and  the 
medical  departments.  Both  should  endeavor  to  at  once  familiarize 
the  new  man  with  every  branch  of  the  employees'  service  department. 
These  first  impressions  go  a  long  way  toward  engendering  in  the 
novice  the  proper  mental  attitude  toward  his  future  work  and  his 
employer. 

RESTAURANT  SERVICE 

Many  industries  provide  proper  restaurant  service  for  their  working 
force,  or  at  least  a  proper  place  in  which  to  eat  their  lunches.  No  group 
can  be  kept  at  the  highest  point  of  efficiency  if  allowed  to  remain  in 
the  department  during  the  noon  hour.  The  change  from  the  working 
place  to  a  suitable  eating  place,  with  the  short  walk  in  the  open  air 
which  this  should  involve,  is  one  of  the  best  efficiency  measures  which 
any  concern  can  adopt  (Fig.  2). 


28 


INDUSTRIAL  MEDICINE   AND   SURGERY 


The  providing  of  the  proper  food  for  employees,  the  supervision  of 
the  sanitary  conditions  of  the  restaurant  and  the  physical  examination 
of  the  help  preparing  or  serving  this  food  is  a  logical  part  of  the 
health  supervision  program. 


Fig.  2. — Employees  Dining  Room.      (Courtesy  Cincinnati  Milling  Machine  Co.) 


RECREATIONAL  SERVICE 

Athletics  has  become  almost  as  popular  among  industrial  employees 
as  among  college  students.  Almost  every  small  concern,  as  well  as  the 
large  ones,  has  its  baseball  team,  its  tennis  team,  and  even  its  golf 
team.  Competitive  games  between  different  working  forces  are 
quite  frequent.  Some  of  the  largest  industries  have  their  athletic 
directors  and  employ  coaches  similar  to  the  athletic  departments  of 
universities.  Teams  are  developed  in  the  different  departments  and 
competition  is  very  keen.  The  annual  field  meet  of  one  of  the  large 
industries  of  Chicago  now  attracts  almost  as  large  a  crowd  as  the 
Conference  Meet  at  the  University  (Fig.  3).  These  athletic  contests 
are  not  hmited  to  the  male  employees,  but  the  girls  have  their  teams 
and  tournaments  likewise. 

No  better  means  of  improving  the  physical  condition  of  employees 
and  of  supervising  their  health  can  be  established  than  this  form  of 
recreation.  The  doctor  should  take  a  very  active  part  in  all  such 
organizations    and    should    constantly    stimulate    the    employees    to 


HEALTH   SUPERVISION 


29 


join  some  one  of  the  athletic  teams,  or  to  join  the  gymnastic  classes. 
In  this  industry,  above  referred  to,  no  person  can  become  a  member 
of  one  of  these  teams  or  take  part  in  any  form  of  physical  recreation 


connected  with  the  plant  without  first  being  thoroughly  examined 
by  one  of  the  doctors  and  pronounced  physically  fit  to  compete.  This 
affords  another  channel  for  health  supervision. 


30  INDUSTRIAL   MEDICINE    AND    SURGERY 

WELFARE  SERVICE 

The  term  "welfare  "  is  disliked  by  many  employees.  It  smacks  too 
much  of  charity.  Nevertheless,  it  is  one  of  the  most  important 
branches  of  the  employees  service  department.  It  has  been  variously 
termed  in  th6  different  industries  as  The  Industrial  Relations  Service, 
The  Employees  Advisors,  The  Sociological  Service,  etc.  No  matter 
by  what  term  you  call  it,  the  work  of  such  a  division  has  a  logical 
place  in  industry,  and  it  must  have  the  closest  connection  with  the 
medical  department. 

Many  times  little  controversies  will  occur  between  a  boss  and  a 
worker,  or  little  injustices  will  be  done  an  employee  and  will  so  prey 
on  his  mind  that  he  first  becomes  mentally  then  physically  unfit. 


All  Ibaaf 

the  lUbfit 

THE 

1 

VICIOUS 

cih;l£ 

Censure  f r  )m 

BOBS 

IiOirarM  Health 
CcmditlW 

■"* Worry  ^— -^ 

and 
nervousness 

psar  otf 
103  to^  job 

Fig.  4. — All  things  tending  to  lower  the  health  of  an  employee  lower  his  efficiency. 
Result — The  Vicious  Circle.  The  preventive  is  a  properly  organized  Human  Main- 
tenance Department. 

Again,  misfits  between  the  job  and  the  man,  misfits  in  temperament 
between  the  boss  and  an  employee,  and  many  other  allied  conditions, 
often  lead  to  the  development  of  a  vicious  circle.  A  misfit  means 
inefficiency,  inefficiency  causes  censure  and  fear  of  losing  his  job, 
this  fear  causes  worry,  then  nervousness,  then  lowered  health 
conditions,  and  this  last  physical  state  makes  him  a  greater  misfit 
(Fig.  4). 

Fears  of  all  kinds;  discontent;  lack  of  living  wage;  worry  over  sick- 
ness or  trouble  at  home;  worry  over  debts;  over  a  love  affair;  over  a 
crime  committed;  bad  habits,  especially  intemperance;  bad  home 
environments;  insufficient  food;  unsanitary  housing  conditions;  and 
innumerable  other  stimuli  for  mental  and  physical  depression,  are 
daily  arising  to  undermine  the  health  of  employees.  It  is  just  as  es- 
sential to  remove  these  conditions  as  it  is  to  make  the  plant  sanitary. 


HEALTH    SUPERVISION  31 

The  ability  to  meet  these  problems  and  to  help  the  medical  de- 
partment to  solve  them  is  the  duty  of  the  so-called  welfare  department. 
Let  the  employees  know  that  their  confidential  friends  are  located  in 
this  department — a  sympathetic  man  for  men,  and  a  woman  for 
women — where  they  can  take  every  problem  of  the  above  nature  and 
receive  help.  In  a  large  industry  these  advisors  furnish  an  excellent 
means  of  personal  contact  between  the  employer  and  employee — 
a  personal  contact  which  is  essential  to  the  comfort  and  well-being  of 
every  worker.  This  department  is  responsible,  to  a  large  extent,  in 
educating  the  force  to  co-operate  in  all  plans  for  accident  prevention 
and  health  supervision. 

INSURANCE  SERVICE 

The  need  of  some  form  of  health  insurance  for  sick  employees  is 
clearly  demonstrated  by  the  fact  that  most  large  industries  have  pro- 
vided mutual  benefit  associations  to  which  the  employer  in  most 
cases  contributes  a  certain  amount  as  well  as  the  employee.  The 
insurance  thus  received  in  case  of  sickness  enables  the  workman  to 
secure  proper  medical  care.  In  most  concerns  membership  in  these 
benefit  associations  is  entirely  voluntary.  The  medical  staff,  which 
is  in  the  best  position  to  realize  the  value  of  this  form  of  insurance, 
should  never  miss  the  opportunity  of  urging  the  employees  to  join 
such  associations.  As  a  rule  these  organizations  are  a  great  stimulus 
to  health  supervision.  Employees  contributing  to  a  benefit  association 
are  easily  impressed  with  the  saving  which  results  from  keeping  the 
sick  rate  down  to  a  minimum  by  proper  preventive  measures. 

BANKING  AND  LOAN  SERVICE 

While  the  banking  department  of  an  industry,  which  provides 
for  savings  at  a  good  rate  of  interest,  may  not  have  a  very  close 
connection  to  the  problems  of  health  supervision,  yet  the  loan  de- 
partment of  this  banking  service  has  one  of  the  closest  connections. 
Time  and  again  the  visiting  nurses  will  report  that  an  employee  who 
is  at  home  sick  needs  special  nursing  service,  or  that  the  home 
conditions  are  responsible  for  the  ill-health,  or  that  an  operation 
requiring  the  expenditure  of  a  considerable  surd  is  necessary,  and  that 
funds  to  meet  the  situation  are  lacking.  After  a  careful  investigation 
the  medical  director  can  recommend  to  the  banking  department  that  a 
loan  of  money  be  granted  such  an  employee.  As  a  rule  these  loans 
are  repaid  in  very  small  amounts  from  the  weekly  wage  after  he  is 
able  to  return  to  work. 

In  one  industry  advantage  has  been  taken  of  this  loan  privilege 
to  urge  employees  to  have  much  needed  dental  work  done.     This 


32  INDUSTRIAL   MEDICINE    AND    SURGERY 

same  concern  has  arranged  for  all  old  employees,  and  all  applicants  for 
work  who  are  accepted,  who  are  in  need  of  glasses  to  correct  defective 
vision  to  buy  the  same,  the  money  being  provided  by  a  loan. 

- — .  HOUSING  AND  COMMUNITY  SERVICE 

No  system  of  health  supervision  in  the  plant  is  complete  that  does 
not  consider  the  home  conditions  of  its  employees.  The  best  means  of 
securing  reports  on  these  home  conditions  is  through  the  visiting  nurses. 
Close  co-operation  with  the  Municipal  Public  Health  Service  will 
enable  the  medical  director  to  secure  the  necessary  correction  of 
unsanitary  conditions  in  the  community. 

If  the  head  of  a  concern,  or  a  man  very  close  to  him,  will  take 
charge  of  this  service  and  will  take  an  active  interest  in  improving  the 
housing  conditions  for  the  entu'e  community  as  well  as  for  his  em- 
ployees, the  greatest  benefits  will  result. 

From  this  short  resume  of  the  functions  of  the  various  services 
represented  in  a  complete  Employees'  Service  Department,  it  is 
quite  evident  that  the  supervision  of  the  health  of  the  employees  forms 
the  very  foundation  of  all  this  work. 

Before  such  a  comprehensive  system  of  supervision  of  the  working 
place,  the  mechanical  appliances  therein,  and  of  the  employees,  can 
be  instituted  the  employers  must  be  educated  to  the  value  of  such  a 
procedure.  Some  employers,  with  a  vision  and  a  social  sense,  will  see 
the  humane  side,  while  others,  of  a  more  calculating  disposition,  will 
look  for  the  dollar-and-cent  value  before  installing  this  system. 

In  those  industries  where  pioneer  work  in  Industrial  Medicine  and 
Surgery  has  been  done,  the  results  should  satisfy  either  of  the  above 
types  of  employers  that  such  supervision  pays  dividends  and  makes  a 
happier,  more  contented  working  force.  It  must  be  the  duty,  there- 
fore, of  every  company  surgeon,  of  every  safety  engineer,  and  of  every 
so-called  welfare  worker,  to  show  that  the  benefits  to  the  employer  are 
in  direct  ratio  to  the  thoroughness  and  completeness  of  the  plan  which 
he  adopts  for  the  Supervision  of  the  Health  of  his  Employees. 

Very  few  employers,  even  in  industries  where  various  plans  of 
health  supervision  have  been  inaugurated,  realize  the  reasons  therefor 
and  the  full  significance  of  this  work.  If  they  would  awake  to  a  real 
comprehension  of  the  value  of  this  form  of  supervision,  a  social  evolu- 
tion would  occur  which  would  react  to  the  great  welfare  of  both  the 
employer  and  employee  and  would  solve  more  labor  disputes  in  a  minute 
than  the  old  system  could  evolve  in  a  year. 

This  is  not  Socialism — so-called — but  it  is  the  broadest  socializing 
influence,  the  most  forward  step  for  preparedness,  and  the  greatest 
conservation  movement  our  country  has  ever  witnessed. 


CHAPTER  II 
THE  PLANT  HOSPITAL  OR  DOCTOR'S  OFFICE 


The  term  "Doctor's  OflEice"  is  usually  applied  to  the  medical  de- 
partment of  an  industry.  In  many  places  it  has  the  functions,  tem- 
porarily, of  a  hospital,  but  because  a  special  license  is  required  to 
operate  a  hospital  and  because  patients  are  seldom  kept  at  the  plant 
over  night,  the  term  "hospital"  is  rarely  used.  In  some  concerns  it 
is  called  the  "Plant  Dispensary,"  in  others,  "The  Medical  Depart- 
ment," and  in  one  industry  the  sign  "Employees'  Doctor"  marks 
the  location  of  this  department. 

Every  industry  with  a  few  hundred  employees,  as  well  as  those 
employing  thousands,  will  find  it  greatly  to  their  advantage  to  have  a 


Fig.  5. — Industrial  Dispensary  at  Primero,  Colo.      {Courtesy  Colorado  Fuel  &  Iron  Co.) 

medical  department  located  somewhere  about  the  plant.  The  smaller 
industries  will  not  require  a  doctor  all  day,  but  there  should  be  a  doc- 
tor's oflfice  and  a  physician  in  attendance  for  a  few  hours  every 
day.  For  industries  of  a  thousand  employees  or  more  it  is  very  im- 
perative that  there  should  be  a  plant  dispensary  and  constant  medical 
attendance.  The  duties  of  the  physician  will  be  taken  up  in  the  next 
chapter. 

The  location  of  the  medical  departments  in  those  industries  which 
have  installed  them  varies  considerably.     Some  have  built  very  hand- 
3  33 


34 


INDUSTRIAL    MEDICINE    AND    SURGERY 


S^. 


X] 

fl        ^ 

1      RF 

=  ^ 

C      =                                                 c 

3                                                  C       3 

=  j 

c      =                     ^ 

1                                           f 1 

■=  = 

= 

—     - 

. 

:^ 

"  H            r 

^       p: 

±J 

S 

u®o 

J.  :2) 

si 

^3 


0    0 


0   0  0  0  0  0© 


K~ 


FiG.  6. — Medical  Department  and  service  room  plan.  Cincinnati  Milling  Machine 
Co.      (From  "Employees  Service  News.") 

Foreword. — The  two  floor  plans  of  the  Employees'  Service  Department  of  the 
Cincinnati  Milling  Machine  Company  include  some  23,000  sq.  ft.  of  floor  space,  which 
is  given  over  to  the  Medical,  Dental  and  Employment  Departments,  the  comforts 
and  convenience  of  the  locker  room,  the  Commissary  and  the  Cafeteria. 

While  the  growth  of  this  Department  has  been  gradual,  the  whole  layout  is  distinc- 
tive in  that  all  of  the  facilities  mentioned  above  have  been  brought  together  and  cen- 
tralized for  the  purpose  of  supervision  and  convenience  and  efficiency  of  operation. 
Considerable  study  is  evidenced  in  its  compact  arrangement,  providing  everything 
that  the  human  engineer  would  first  think  of,  except,  perhaps,  recreational  facilities. 

Looking  first  at  the  office  end  of  the  Employees'  Service  Department  one  notes 
that    the  Employment  Department  and  the  Medical  Department  are  side  by  side. 


THE    PLANT    HOSPITAL    OR    DOCTOR' S    OFFICE  35 

some  buildings  in  close  proximity  to  the  plant  (Fig.  5).  Others  have; 
set  aside  spacious,  well  lighted  rooms  directly  in  the  plant  and  equipped 
them  as  the  most  ideal  doctor's  offices,  surpassing  in  many  respects 
the  private  offices  of  any  physician  in  the  country.  Many  of  these 
would  delight  the  heart  of  the  most  fastidious  physician. 

Too  often,  however,  the  company  physician  has  been  unable  to 
demonstrate  the  value  of  efficient  medical  service  to  his  employers 
and  as  a  result  they  have  furnished  him  very  poor  quarters  in  which 
to  work.  Or  the  management  may  feel  that  the  medical  department 
is  an  unprofitable,  expensive  necessity  and  therefore  crowd  it  into 
some  place  where  it  will  not  take  up  space  capable  of  productivity. 
The  best  argument  against  this  attitude  is  that  some  of  the  largest, 
most  successful  concerns  have  assigned  the  best  location  in  their  plants 
to  their  medical  departments. 

Some  time  ago  a  successful  business  man  visited  one  of  the  pro- 
gressive industries  and  made  a  careful  inspection  of  their  doctor's 
office.  When  he  had  finished  he  said :  "This  is  all  very  fine  but  how 
can  you  afford  to  give  over  such  a  large  amount  of  valuable  space  to 
your  Medical  Department?"  The  official  of  the  concern  who  was 
present  said:  "Why,  man,  this  department  pays  the  biggest  dividends 
of  any  of  our  departments  and  therefore  it  deserves  all  the  space  it 
needs." 

The  selection  of  the  proper  location  for  the  doctor's  office  or  plant 
dispensary  must  depend  upon  many  local  factors,  but  a  few  general 
rules  can  be  laid  down  which  should  be  of  great  assistance  to  the 
company  surgeon. 

1.  Choose  a  central  location  in  the  plant  where  the  doctor's  office 
will  be  the  most  available  to  the  greatest  number  of  employees. 

2.  If  one  portion  of  the  plant  is  engaged  in  work  where  accidents 
are  more  liable  to  occur,  the  office  should  be  located  in  that  vicinity. 

3.  Whenever  possible  the  employment  department  should  be 
in  close  proximity  so  as  to  facilitate  the  examination  of  applicants 
for  work  (Fig.  6). 

separated  only  by  the  employees'  entrance,  whose  doors  are  locked  at  the  start- 
ing hour.  Thereafter  all  late  comers  must  pass  through  the  Employment  Office, 
where  the  clerk  makes  record  as  to  his  cause  of  lateness.  Similarly,  all  men  leaving 
the  shop  at  irregular  periods  can  only  pass  out  through  the  Employment  Department 
and  by  the  same  clerk,  who  makes  record  of  his  exit.  All  successful  applicants  for  jobs 
readily  pass  into  the  Medical  Department  for  a  physical  examination. 

After  starting  hours  the  doors  leading  from  the  locker  room  to  the  plant  are  locked. 
The  floor  arrangement  shown  indicates  how  accessible  the  Medical,  Dental,  Employ- 
ment and  Paymaster's  Offices  are  to  all  the  men  of  the  shop.  Complete  privacy  is 
assured  any  employee  who  wishes  to  discuss  his  personal  affairs  with  the  Employment 
Manager,  the  Assistant  Superintendent,  or  the  Medical  Chief,  who  happens  also  to  be 
the  Director  of  the  Employees'  Service  Department.  It  is  here  also  that  office  rooin 
is  provided  for  the  group  of  men  who  manage  the  Health  and  Insurance  Association 
of  the  plant. 

The   floor   plan   is   practically   self-descriptive  '  and   needs   no   further   elaboration. 


36  INDUSTRIAL   MEDICINE    AND    SURGERY 

4.  It  should  not  be  placed  in  a  noisy  portion  of  the  plant  where 
the  rumble  of  machinery,  or  of  heavy  trucks,  etc.,  will  interfere  with 
the  efficient  use  of  the  stethoscope  in  examinations. 

5.  The  rooms  should  be  spacious,  well  ventilated  and  well  lighted 
and  of  sufficient  number  that  the  work  can  be  done  with  more  or  less 
privacy. 

6.  The  doctor's  office  should  at  all  times  be  a  model  of  cleanliness. 

7.  Whenever  the  size  of  the  industry  warrants  it  the  office  should 
be  located  upon  the  grounds  or  in  the  building. 

8.  Keep  the  medical  work  centralized  in  one  office  as  far  as  pos- 
sible, but  if  the  plant  is  scattered,  it  may  be  necessary  to  have  sub- 
stations. 

9.  Whenever  practicable  a  separate  building  in  close  proximity  to 
the  plant  should  be  used.  This  affords  better  light  and  ventilation 
and  quieter  examining  and  rest  rooms.  Sick  and  injured  employees 
are  also  exposed  to  less  unpleasant  publicity. 

The  minimum  requirements  for  the  doctor's  office  in  an  industrial 
concern,  suitable  for  conducting  the  medical  examination  of  employees, 
can  best  be  shown  by  quoting  from  the  report  of  the  "Committee  on 
Factories,"  made  to  the  Chicago  Tuberculosis  Institute  in  1913. 

This  committee  consisted  of : 

Dr.  Harry  E.  Mock,  Sears,  Roebuck  and  Company,   chairman. 

Dr.  A.  M.  Harvey,  Crane  Company. 

Dr.  James  A.  Britton,  International  Harvester  Company. 

Dr.  W.  H.  Lipman,  Swift  and  Company. 

Dr.  L.  Z.  Little,  Western  Electric  Company. 

"  'Provision  for  the  Medical  Office  and  Equipment  in  an  Industrial 
Concern'  was  the  subject  of  the  committee's  report. 

"That  it  marked  an  epoch-making  advance  in  the  promulgation  of 
the  systematic  supervision  of  the  health  of  employees,  was  pointed  out 
in  the  words  of  the  chairman  of  the  Factory  Committee,  Dr.  Theodore 
Sachs:  'The  most  significant  point  in  connection  with  this  report  is 
that  in  a  comparatively  short  period  of  three  years  or  so,  the  medical 
departments  in  the  industrial  concerns  became  an  important  integral 
part  of  the  concern  and  this  report  certainly  presents  a  good  basis  for 
all  others,  who  are  contemplating  the  installation  of  a  health  depart- 
ment, to  follow.' " 

The  committee  report  follows: 

"In  the  judgment  of  your  committee,  the  subject  matter  proposed 
for  their  consideration  was  entirely  too  broad : 

''First. — Because  a  great  many  industries  already  have  a  medical 
department  in  connection  with  their  plants. 

"Second. — Because  an  industry  planning  to  take  up  this  medical 
work  should  first  choose  a  competent  physician  to  take  charge,  and 


THE    PLANT    HOSPITAL    OR    DOCTOR'S    OFFICE  37 

the  arrangement,  equipment,  size  and  location  of  the  doctor's  office 
should  be  left  to  his  judgment  and  discretion  in  practically  every 
case. 

'^ Third. — Because  most  industries  contemplating  the  installation 
of  a  doctor's  office  must  of  necessity  have  in  mind  the  care  of  injured 
employees  as  one  of  the  chief  duties  of  the  medical  department. 

"Therefore,  we  have  dealt  with  this  subject  from  one  aspect  only, 
namely:  'What  should  be  the  minimum  requirements  for  the  doctor's 
office  and  equipment,  in  an  industrial  concern,  suitable  for  conducting 
the  medical  examination  of  employees.' 

"The  ideal  arrangement  would  be  a  group  of  offices,  well-lighted, 
well-aired,  removed  from  all  noises,  and  housed  in  a  building  prefer- 
ably detached  from  the  plant,  but  conveniently  accessible  to  a  majority 
of  the  employees. 

"There  are  now  a  few  such  ideal  doctors'  offices  in  connection  with 
certain  industries  here  in  Chicago,  but  it  must  be  remembered  that  it 
has  taken  years  to  accomplish  this. 

"It  can  hardly  be  expected  that  a  medical  department  will  be  in- 
stalled on  such  a  grand  scale  before  its  value  has  been  absolutely 
proven  to  an  industrial  concern. 

"As  stated  before,  most  large  industries  already  have  a  medical 
department  in  connection  with  their  plant  for  the  care  of  accident  cases. 
These  offices  can  be  used  at  certain  times  of  the  day  for  the  examina- 
tion of  the  employees.  As  the  value  of  this  procedure,  in  the  increased 
efficiency  of  the  working  force,  is  demonstrated,  larger  and  better 
equipped  offices  will  undoubtedly  be  estabhshed. 

"For  small  concerns  desiring  to  adopt  a  system  of  medical  examina- 
tion of  employees,  but  where  the  installation  of  a  doctor's  office  is 
not  practical  and  space  is  not  available,  this  can  usually  be  accom- 
plished by  sending  the  employees  to  a  doctor's  office  in  the  neighbor- 
hood ;  or  a  group  of  small  industries  can  unite  and  employ  a  doctor 
who  will  visit  them  in  succession.  Every  concern,  no  matter  how  small 
could  give  a  small  office  to  the  doctor  for  an  hour  a  day  where  he  could 
conduct  the  examinations.  The  specimens  for  the  laboratory  work 
could  even  be  carried  back  to  this  doctor's  own  office  for  analysis. 

"For  a  concern  contemplating  the  installation  of  an  office  for 
the  purpose  of  examination  of  employees  the  following  should  be  the 
minimum  requirements: 

"Location. — This  may  be  directly  in  connection  with  the 
plant,  but  an  effort  should  be  made  to  choose  as  quiet  a  location  as 
possible.  Thus,  noisy  machinery  overhead  or  in  the  adjoining  room 
may  detract  to  a  certain  extent  from  the  value  of  the  examination. 

"Offices. — The  size  and  number  of  these  must  depend  upon  the 
number  of  employees  to  be  examined  daily.     For  this  reason,   the 


38  INDUSTRIAL   MEDICINE    AND    SURGERY 

physician  in  charge  should  be  chosen  first  and  consulted  freely  as  to 
his  needs.     The  following  rooms  are  necessary,  however : 

"A  waiting  room  equipped  with  chairs  or  suitable  benches  for 
seating.  A  separate  waiting  room  for  men  and  women  is  a  more  ideal 
arrangement,  but  not  at  all  necessary  (Fig.  7). 

"A  general  office:  where  a  stenographer  can  work  and  where  files 
can  be  kept.  It  is  very  essential  that  the  most  careful  record  be 
kept  on  each  case  examined  (Fig.  8). 

"An  Examining  Room. — This  should  be  made  as  quiet  as  possible, 
should  be  well-lighted,  even  if  artificial  light  is  necessary  to  accomplish 


Fig.  7. — Waiting  Room. 

this,  and  should  be  completely  closed  off  from  the  rest  of  the  rooms. 
It  should  contain  a  chair  for  the  doctor,  a  stool  (a  revolving  piano  stool 
is  ideal)  for  the  employee,  and  a  simple,  padded  examining  table,  for 
frequently  it  is  desired  to  examine  the  employee  in  a  recumbent  posi- 
tion; also  a  small  stand  for  writing  or  on  which  to  lay  the  stethoscope, 
the  blood  pressure  outfit  or  other  instruments.  Two  hooks  placed 
in  the  wall  can  be  used  as  clothes  hangers. 

"If  a  number  of  employees  are  to  be  examined  each  day,  two  or  more 
such  rooms  should  be  thus  equipped.  An  ideal  arrangement  is  to  have 
a  dressing  room  in  connection  with  a  small  examining  room.  Two 
or  more  men  can  then  remove  their  clothing  in  the  dressing  room 
and  come  into  the  examining  room  prepared  for  the  examination. 
Thus,  the  doctor  can  remain  continually  in  this  room,  examining  the 
employees  as  they  are  brought  to  him. 

"For  examination  of  the  female  help,  the  separate  dressing  room  and 
examining  room  is  very  essential.  The  girl  employee  should  remove 
her  waist  and  underclothing  over  her  chest  in  the  dressing  room,  and 
the  nurse  should  then  cover  her  chest  and  shoulders  with  a  sheet  or  an 


THE    PLANT    HOSPITAL    OR    DOCTOR' S    OFFICE  39 

examination  cape.  The  girl  is  then  taken  before  the  doctor  to  be 
examined.  In  all  cases  the  nurse  should  be  present  when  a  girl  is 
examined. 

"A  History  Room. — This  is  not  essential,  as  the  history  of  each 
case  may  be  taken  in  the  examining  room ;  but  it  saves  a  great  deal  of 
the  physician's  time  if  a  separate  history  room  is  provided.  Here,  the 
temperature,  pulse,  height,  and  weight  of  the  employee  can  be  taken, 
and  the  few  points  desired  in  regard  to  his  age,  nationality,  and  past 
history  obtained.  This  can  be  done  by  a  nurse,  or,  if  the  nurse's  time 
is  occupied  elsewhere,  by  a  well-trained  attendant. 


Clerical  and  Filing  Room  in  Doctor's  Office. 


"A  Laboratory. — This  is  absolutely  essential,  for  no  examination  is 
complete  without  certain  laboratory  tests  are  made.  It  should  be 
equipped,  therefore,  for  careful  urinalysis  with  a  microscope,  blood 
counting,  and  blood  pressure  apparatus  (Figs.  9  and  10). 

''  A  private  office  for  the  physician  in  charge  is  desirable,  where  con- 
fidential conversations  with  the  various  employees  may  be  conducted. 
In  the  absence  of  such  an  office,  one  of  the  examining  rooms  can  be 
used  for  this  purpose. 

"  As  the  medical  examination  of  employees  is  such  a  broad  subject 
and  as  there  are  so  many  problems  to  be  considered,  we  would  recom- 
mend that  this  organization  appoint  a  permanent  committee  to  meet 
with  and  co-operate  with  other  committees,  such  as  the  Industrial 
Hygiene  Committee  of  the  Ilhnois  Manufacturers  Association,  the 
Health  Committee  of  the  National  Safety  Council  and  the  Health 
Committees  of  the  various  labor  organizations  who  are  also  considering 
this  subject  of  the  medical  examination  of  employees." 

The  above  report  covers  only  the  essentials  for  a  doctor's  office, 
equipped  for  the  medical  examinations.  In  addition  this  office  must 
have : 


40 


INDUSTRIAL    MEDICINE    AND    SURGERY 


A  surgical  room,  where  the  accident  cases  can  receive  immediate 
attention  and  where  the  subsequent  dressings  can  be  done.  If  the 
industry  employs  a  large  proportion  of  women,  there  should  be  two  of 


Fig.   9. — Laboratory  in  hospital  of  Colorado  Fuel  and  Iron  Co. 


.^^^    }    "^ 


Fig.   10. — Laboratory  in  Medical  Department.      {Ford  Co.) 

these  rooms.  Good  light  and  ventilation  are  very  essential.  They 
should  be  closed  off  from  the  rest  of  the  office  as  the  sight  of  wounds 
being  dressed  will  tend  to  prevent  employees  from  coming  to  the  office. 


THE  PLANT  HOSPITAL  OR  DOCTOR  S  OFFICE 


41 


Here  above  all  places  cleanliness  must  be  the  rule.  The  room  should 
be  white  and  furnished  in  white  enamel  (Fig.  11).  Instruments,  as 
far  as  possible,  should  be  kept  out  of  sight.  The  furniture  should 
consist  of: 

(a)  White  enamel  table  where  the  patient  can  lie  down  if  neces- 
sary. 

(6)  White  enamel  dressing  table. 

(c)  White  enamel  stand  for  instrument  sterilizer. 

(d)  Glass  jars  for  the  dressings. 

(e)  Instrument  cabinet. 

(/)  The  few  necessary  drugs. 

(g)  White  enamel  chairs  or  stools. 


Fig.   11. — Surgical  dressing  room  in  Medical  Department.      (Courtesy  Ford  Co.) 


(/),)  White  enamel  stands  suitable  for  resting  of  leg  or  arm  for 
dressing  wounds  of  these  extremities. 

(i)  Hot  and  cold  running  water  (foot  control). 

(j)  As  an  adjunct  to  this  equipment  there  should  be  space,  or  pref- 
erably a  separate  room,  for  hydrotherapy  and  baking  apparatus. 

A  sterilizing  room,  where  all  dressings  used  on  the  wounds  can  be 
thoroughly  sterilized. 

An  X-ray  Laboratory. — This  is  very  essential  in  connection  with 
every  doctor's  office  where  accidents  of  a  severer  nature  are  liable  to 
occur. 


42  INDUSTRIAL   MEDICINE    AND    SURGERY 

Rest  Rooms. — One  for  the  women  employees  and  one  for  the  men 
should  be  provided  in  every  industry  and  should  be  in  connection  with 
the  doctor's  office.  Sudden  acute  illness  among  the  employees  will 
often  necessitate  their  lying  down  until  a  cab  or  ambulance  can  be 
called  to  take  them  home  or  to  the  outside  hospital.  Likewise,  a  suit- 
able rest  room  will  enable  employees  to  overcome  some  temporary 
condition  and  return  to  work  after  an  hour  or  two.  The  value  of 
these  rest  rooms  will  be  touched  on  in  subsequent  chapters. 

Proper  toilet  facilities  must  be  provided  in  the  doctor's  ofl&ce. 
Bath  tubs  in  connection  with  these  will  frequently  be  of  advantage. 
Cases  of  heat  exhaustion  have  undoubtedly  been  saved  by  the  imme- 
diate use  of  a  tub  of  cold  water.  Again  the  nurses  by  keen  diplomacy 
have  persuaded  employees,  unused  to  a  bath  more  often  than  twice 
a  year,  to  enter  these  tubs  and  learn  the  joys  of  a  good  bath. 

A  dental  office  and  rooms  for  eye,  ear,  nose  and  throat  work 
are  most  valuable  additions  to  this  office  and  are  necessary  when  a 
concern  is  sufficiently  farsighted  to  see  the  great  economic  value  of 
an  efficient,  comprehensive  system  of  Industrial  Medicine  and 
Surgery. 

When  a  small  number  of  persons  are  employed  it  is  unprofitable 
to  have  a  medical  department  connected  with  the  plant.  In  this 
case  arrangements  should  be  made  with  a  nearby  physician  to  render 
immediate  care  to  their  injured  and  to  use  his  office  for  the  purpose  of 
making  the  medical  examinations.  This  physician  should  visit  the 
plant  once  or  twice  a  week  to  make  sanitary  inspections  and  in  other 
ways  supervise  the  health  of  these  employees. 

In  some  cities  several  small  employers  have  combined  and  selected 
a  physician  with  a  central  emergency  office  convenient  to  all  their 
plants  to  carry  on  this  medical  and  surgical  work  for  them.  The  point 
is  that  every  employer  should  voluntarily  assume  this  protection  for 
his  employees  or  the  states  should  pass  legislation  making  such  a  pro- 
cedure compulsory. 


CHAPTER  III 
THE  MEDICAL  STAFF 

SIZE,  DUTIES,  AND  ADJUNCTS 

The  character  of  the  work,  the  number  of  employees,  and  the  size 
of  the  industry  must  determine  the  number  of  doctors,  the  location  of 
the  plant  dispensary,  and  the  amount  of  service  necessary  to  conduct 
a  comprehensive  system  of  health  supervision.  These  are  details 
which"  each  company  surgeon  must  meet,  and  which  will  certainly 
be  subjected  to  changes  with  the  growth  of  his  work.  For  instance, 
one  industry,  a  pioneer  in  this  type  of  medical  and  surgical  work,  has 
gradually  expanded  its  space,  equipment  and  medical  staff  from  a 
small  four  room  office  with  one  doctor  and  two  nurses  in  1909,  to  a 
large  eighteen  room  office  with  ten  doctors,  twelve  nurses,  and  two 
dentists  in  1916.  These  doctors  spend  d}-2  hours  per  day  at  this 
work,  so  rotating  that  there  is  always  one  or  more  in  attendance  at 
the  company  office. 

While  many  expert  company  surgeons  devote  all  of  their  time  to 
the  industries  employing  them,  yet  as  a  rule  better-trained  and  more 
able  physicians  can  be  secured,  if  employers  require  them  to  give  only 
a  part  of  their  time  to  this  work.  This  perhaps  would  not  be  true  if 
they  would  pay  a  salary  commensurate  to  the  services  rendered  by  the 
up-to-date  company  surgeon.  Industry  should  require  the  very  best 
talent  in  the  medical  profession,  but  such  men  can  make  a  much  greater 
income  in  private  practice.  Undoubtedly  the  time  is  rapidly  approach- 
ing when  large  salaries  wiU  be  paid  in  order  to  engage  the  best  medical 
and  surgical  talent  in  the  country  for  this  type  of  work. 

However,  an  industry  can  employ  two  physicians  of  this  caliber 
for  part  time  service,  and  their  combined  salaries  will  be  much  less 
than  if  one  of  them  gave  his  full  time  to  the  work.  An  additional 
incentive  to  a  good  internist  or  surgeon  entering  upon  such  an  arrange- 
ment is  the  great  amount  of  clinical  material  placed  at  his  disposal. 
These  medical  departments  of  industries  afford  the  greatest  human 
laboratories  for  study  ever  offered  to  a  physician. 

The  situation  is  quite  analogous  to  that  found  in  our  leading 
medical  schools.  The  heads  of  departments  and  those  associated  with 
them  give  a  portion  of  each  day  to  teaching  and  clinical  work — the 
rest  of  their  time  is  given  to  private  practice,  study  and  investiga- 
tion.    Because  of  their  clinical  experience,  plus  the  broadening  in- 

43 


44  INDUSTRIAL   MEDICINE    AND    SURGERY 

fluence  of  their  private  and  public  work,  these  men  become  the  leaders 
and  scholars  in  our  profession,  and  their  influence  in  the  community  at 
large  is  much  greater  than  if  they  devoted  their  entire  time,  on  an 
inadequate  salary,  to  teaching  in  a  medical  school.  The  tendency  for 
medical  teachers  to  give  full  time  to  this  work  is  due  to  the  willingness 
of  a  few  Universities  to  pay  an  adequate  income.  But  the  best  full 
time  teachers  are  those  who  have  had  the  experience  and  broadening 
influence  of  actually  practising  medicine  previous  to  limiting  their 
work  to  teaching.  (Certain  laboratory  men  and  specialists  are 
exceptions,  of  course.) 

So  with  a  company  surgeon — the  greater  name  and  prestige  he 
can  build  for  himself  in  his  community,  the  greater  his  value  to  the 
industry  with  which  he  is  connected,  and  the  better  his  influence 
over  the  employees  and  their  confidence  in  him. 

As  stated  before,  the  composition  of  the  medical  staff  will  vary 
according  to  the  number  of  employees  and  the  size  of  the  industry. 
The  sex  of  the  employees  also  plays  a  part  in  this  decision. 

The  first  requisite  is  a  well-trained  medical  man  in  charge  of  the 
work,  known  as  the  Medical  Director  or  Chief  Surgeon.  He  should 
always  be  a  man,  if  the  working  force  is  entirely  male  or  composed 
of  both  male  and  female  help.  In  those  concerns  employing  chiefly 
women  a  properly  qualified  woman  physician  will  undoubtedly  be  of 
the  greatest  service.  Where  the  amount  of  work  demands  it,  one  or 
more  medical  assistants  must  be  employed.  A  nurse,  preferably 
female,  is  the  most  valuable  aid  to  the  medical  staff.  Her  duties 
are  outlined  in  a  subsequent  chapter. 

If  the  size  of  the  plant  warrants  it,  an  oculist  and  dentist  should  be 
employed.  At  least  arrangements  should  be  made  with  some  able 
ocuHst  and  good  dentist  to  take  care  of  this  branch  of  the  medical  work 
at  their  private  offices. 

The  medical  man  entering  this  field  must  be  a  very  broadly  trained 
physician.  Some  of  the  largest  industries  can  afford  to  have  several 
doctors  on  their  staff  and  thus  can  divide  the  work  into  its  various 
specialties;  but  even  here  the  chief  of  staff  must  be  trained  thoroughly 
in  all  the  branches  of  this  work.  In  the  smaller  corporations,  however, 
the  company  surgeon  must  be  a  surgeon,  an  internist,  a  diagnostician, 
a  sanitation  expert,  and  an  all-around  medical  utility  man. 

The  duties  and  size  of  the  staff  can  best  be  illustrated  by  outHn- 
ing  specific  examples  in  several  typical  industries. 

I.  A  stove  factory  employing  approximately  800  men.  This 
factory  has  a  one  room  doctor's  office,  well  hghted,  and  equipped 
with  sufficient  surgical  appliances  and  dressings  to  do  all  types  of 
emergency  surgery,  as  well  as  routine  ambulatory  dressings;  a  chair 
and  table  suitable  for  making  medical  examinations;  a  small  but 


THE    MEDICAL    STAFF  45 

practical  and  adequate  laboratory.  A  physician,  whose  office  is  two 
miles  away,  is  employed  on  a  monthly  salary  by  this  concern.  He  is 
a  general  practitioner — a  good  internist  and  a  good  surgeon,  and  a 
man  who  keeps  abreast  of  new  developments  in  medical  science.  He 
visits  the  plant  for  two  hours  every  morning. 

His  duties  there  consist  of,  dressing  all  minor  accident  cases; 
examining  any  new  employees  hired  within  the  last  24  hours  (he  calls 
early  in  the  morning  and  the  concern  tries  to  have  all  applicants  for 
work  examined  before  employing  them) ;  examining  all  employees  who 
have  been  absent  on  account  of  sickness;  examining  a  certain  number 
of  the  old  working  force,  so  that  those  needing  it  will  have  their  peri- 
odical physical  examinations;  and  making  the  necessary  sanitary 
inspections  to  properly  supervise  the  health  of  all  the  employees. 

One  employee  in  this  concern  has  been  carefully  trained  in  first 
aid  work.  All  workers  sustaining  injuries,  no  matter  how  slight, 
are  made  to  report  to  the  doctor's  office  at  once.  Here,  during  the 
physician's  absence,  this  first  aid  man  applies  iodine  and  a  simple  ster- 
ile dressing  to  only  the  very  minor  accidents  and  allows  them  to  wait 
until  the  next  morning  before  seeing  the  doctor.  To  the  other  cases 
he  applies  iodine  and  a  sterile  dressing  and  sends  them  at  once  to  this 
physician's  private  office.  Or,  if  the  case  is  serious,  the  doctor  is 
immediately  called  to  the  plant.  He  has  two  associates  who  are  on 
call  for  these  cases  providing  he  is  away  from  the  office. 

This  physician  has  a  similar  arrangement  with  two  smaller  indus- 
tries but  calls  only  twice  a  week  at  their  plants.  Their  accident  cases 
are  sent  to  his  office  for  dressings,  but  all  medical  examinations  are 
made  on  his  calls  at  these  plants.  His  income  is  greatly  enhanced  by 
this  work,  and  at  the  same  time  he  is  rendering  a  valuable  service  to 
over  two  thousand  employees  in  his  city.  And  for  a  nominal  cost 
these  employers  are  increasing  the  efficiency  of  their  working  force  to  a 
greater  extent  than  they  realize. 

II.  A  large  department  store  employing  about  4000  people.  This 
store  has  a  woman  physician  who  spends  her  mornings  at  their  doctor's 
office.  In  the  afternoon  she  does  a  similar  work  in  a  second  but  smaller 
store.  She  dresses  the  few  accident  cases  which  arise  and  spends 
the  remainder  of  the  time  in  rendering  medical  care  to  the  girls  who 
become  sick  while  at  work,  in  medical  examinations  of  all  applicants  for 
work  and  similar  examinations  among  the  old  employees,  and  in  general 
health  supervision.  Besides  store  sanitation  this  involves  a  close 
study  of  working  conditions,  home  conditions,  habits,  and  environ- 
ments of  the  girls,  and  all  matters  which  would  tend  to  undermine  their 
health.  She  has  a  wonderful  personality  which  enables  her  to  gain 
the  girls'  confidence. 

Three  trained  nurses  assist  in  this  work.     One  is  at  the  doctor's 


46  INDUSTRIAL   MEDICINE    AND    SURGERY 

office  at  all  times  to  render  first  aid  in  her  absence,  in  the  case  of  either 
accident  or  sickness.  The  other  two  visit  the  sick  employees  in  their 
homes  and  render  any  aid  they  can  to  these — showing  the  friendly 
interest  of  the  concern  in  their  welfare.  The  information  gathered 
by  the  nurses ,  gives  the  doctor  her  insight  into  the  home  environ- 
ments and  habits  of  the  girls. 

This  woman  besides  being  a  physician  to  the  individual  case,  pre- 
scribing a  pill  here  and  bandaging  a  cut  finger  there,  is  also  the  medical 
advisor  and  confidential  friend  to  7000  girls,  and  has  become  an  effi- 
ciency expert  to  her  employers.  A  job  certainly  big  enough  for  any 
individual! 

Large  rooms  for  recreation  have  been  set  aside  for  these  employees. 
Adjoining  them  are  dining  rooms  where  food,  prepared  by  the 
direction  of  the  doctor,  is  served  at  a  rate  below  that  of  outside  restau- 
rants. The  lunch  hour  has  been  extended  from  3^^  hour  to  %  hour, 
and  this  allows  the  girls  to  dance  and  play  games  during  the  noon 
period,  thus  returning  to  their  work  refreshed  and  energetic.  Evening 
entertainments  have  been  provided  which  are  much  more  beneficial 
to  the  girls  from  both  a  moral  and  health  standpoint  than  the  average 
festivities  of  the  city.  Many  and  varied  talks  to  the  employees,  in 
groups  and  individually,  have  corrected  conditions  in  their  diets, 
modes  of  dressing,  improper  sleeping  rooms,  loss  of  sleep,  and  unsani- 
tary home  surroundings.  These,  combined  with  corrective  measures 
in  the  individual  from  a  medical  and  surgical  standpoint,  have 
increased  the  efficiency  of  the  forces  in  these  stores  and  decreased  time- 
loss  on  account  of  sickness  almost  fifty  percent.  It  is  no  wonder 
that  the  proprietors  have  installed  ventilating  systems,  inverted 
lighting  systems,  and  many  other  costly  yet  helpful  health  measures, 
on  the  recommendations  of  this  physician. 

III.  An  electrical  concern  with  5000  employees.  Here  we  have 
the  example  of  the  chief  surgeon  as  a  full-time  man,  with  a  full-time 
assistant.  This  concern  has  a  well-equipped,  four-room  doctor's 
office  and  an  additional  staff  of  four  nurses.  The  work  was 
primarily  surgical,  but  gradually  this  has  extended  until  the  assistant's 
time  is  devoted  altogether  to  the  medical  examination  of  employees. 
Applicants  for  work  are  not  examined  until  they  have  been  employed 
for  at  least  three  months.  This  plan  is  adopted  as  it  obviates  the 
examining  of  many  applicants  who  only  remain  a  week  or  a  month  on 
the  job.  Naturally  the  two  chief  purposes  of  a  medical  examination  of 
applicants  are  lost  by  such  a  procedure ;  namely,  the  protection  of  the 
old  force  from  contagion,  and  the  proper  selection  of  a  job  for  the 
partially  handicapped. 

One  nurse  is  constantly  in  attendance  at  the  doctor's  office  as  an 
assistant  to  the  physicians.     The  other  three  nurses  spend  their  time 


THE    MEDICAL    STAFF  47 

iu  visiting  all  absent  employees.  These  visits  are  fifty  percent  helpful 
to  the  working  force  and  fifty  percent  for  the  purpose  of  spying  on  the 
employees  to  ascertain  why  they  are  away  from  work.  While  the 
latter  work  may  be  necessary,  yet  it  cannot  be  connected  with  the 
former  and  give  the  desired  results  from  a  medical  standpoint.  Visit- 
ing nurses'  work  among  employees,  to  be  beneficial  and  to  have  the 
co-operation  of  the  entire  force,  must  be  based  on  altruistic,  humani- 
tarian grounds  only — friendly  interest,  health  supervision,  and  a  desire 
to  help  whenever  and  wherever  possible. 

IV.  A  large  automobile  concern  employing  some  30,000  men  and 
women.  The  system  herein  outlined  is  similar  in  many  respects  to 
that  in  vogue  in  several  of  our  large  industrial  establishments. 

Here  we  have  the  example  of  the  large,  full-time  medical  staff, 
which  is  very  efficient,  and  is  represented  by  some  of  the  best  medical 
and  surgical  talent  of  the  country,  because  this  concern,  and  many  like 
it,  are  willing  to  pay  for  the  best,  especially  for  the  chief  of  staff. 

The  central  doctor's  office  consists  of  twelve  rooms,  large,  airy, 
well  lighted,  with  tile  floors,  white  walls,  and  furnished  in  white 
enamel  fixtures.  It  has  a  large  waiting  room,  two  private  consultation 
rooms,  two  surgical  dressing  rooms,  a  room  for  eye,  ear,  nose  and  throat 
work,  examining  rooms,  a;-ray  laboratory,  and  a  general  laboratory. 

In  addition  to  this  central  office  there  are  six  medical  sub-offices, 
or  first  aid  stations.  These  are  in  charge  of  well-trained,  first  aid 
laymen  whose  duties  are  to  render  immediate  care  to  any  injured 
employee,  and,  except  in  case  of  very  slight  injury,  to  see  that  the 
patient  goes  at  once  to  the  central  office  for  care  by  the  physician  in 
charge.  The  reduction  in  infections  and  other  complications  more  than 
pays  for  the  extra  expense  of  maintaining  these  first  aid  stations.  Be- 
sides this  first  aid  work,  these  men  have  been  trained  as  experts  in 
accident  prevention.  Whenever  an  accident  occurs  they  investigate 
the  cause  and  report  the  same  in  great  detail  with  recommendations 
for  its  correction. 

The  duties  of  the  medical  staff  are  as  follows : 

1.  To  render  proper  and  immediate  surgical  care  to  the  injured 
coming  directly  to  the  office  or  sent  there  from  the  first  aid  stations. 
The  major  injuries  requiring  outside  hospital  care  are  sent  there  in  an 
ambulance,  and  the  surgeon  on  the  staff  goes  to  the  hospital  and  does 
whatever  operative  work  is  indicated.  Neither  this  surgeon  nor  any 
of  the  others  on  the  staff  are  permitted  to  have  private  cases.  Their 
time  is  given  entirely  to  this  concern. 

2.  To  examine  all  applicants  for  work  and  to  so  co-operate  with  the 
employment  department  that  all  new  employees  are  placed  at  work  for 
which  they  are  physically  fit. 

3.  To    examine    and    re-examine    any   employee   whenever  some 


48  INDUSTRIAL   MEDICINE    AND    SURGERY 

condition  in  the  man  himself,  in  his  work,  or  in  his  environment  indi- 
cates the  necessity. 

4.  To  periodically  examine  those  with  handicapped  conditions  who 
were  allowed  to  go  to  work,  or  who  have  been  discovered  subsequent  to 
employment  and  to  place  them  at  suitable  occupations. 

5.  To  supervise  the  medical  or  surgical  treatment  which  the  sick 
employees  receive  in  their  homes  from  their  family  physicians.  When 
mal-treatment  indicates  the  need,  the  medical  staff  of  this  industry  does 
not  hesitate  to  take  charge  of  the  case. 

6.  Special  medical  care  is  given  to  tuberculous  employees  in  a 
sanatorium  owned  bj''  the  concern. 

7.  To  co-operate  with  the  welfare  or  sociological  department  on  all 
matters  pertaining  to  the  health  of  the  employees  either  in  their 
working  place  or  in  their  homes. 

The  medical  staff  necessary  to  carry  on  this  work  consists  of  seven 
doctors,  four  nurses  and  twelve  lay  assistants.  Much  of  the  visiting 
work  done  by  nurses  in  other  establishments  is  left  to  the  visitors  of 
the  sociological  department  in  this  plant. 

V.  The  Industrial  Medical  Office  Serving  Several  Industries.^ — 
Several  cities  have  examples  of  this  system,  but  Doctors  Selby,  Heath 
and  Heim  of  Toledo,  Ohio,  have  developed  it  to  the  greatest  extent. 

It  consists  of  establishing  a  well-equipped  doctor's  office  in  the 
vicinity  of  several  industries.  These  concerns  can  thus  secure  excel- 
lent medical  and  surgical  services  for  their  employees  at  a  much  less 
cost  than  if  they  created  a  separate  system.  Three  such  offices  are 
maintained  in  different  sections  of  the  city  by  these  physicians. 

In  the  mornings  they  spend  their  time  at  these  offices  and  in  the 
afternoon  at  the  hospital,  caring  for  the  more  serious  cases  it  has  been 
necessary  to  refer  there.  During  their  absence  from  these  offices  as- 
sistants are  constantly  in  attendance  to  render  emergency  treatment 
and  to  call  one  of  the  doctors  in  the  more  serious  cases. 

Nurses  are  employed  to  assist  the  doctors  in  their  surgical  dress- 
ings and  to  do  visiting  nurses'  work  for  those  concerns  employing  this 
branch  of  the  service. 

The  doctors  have  influenced  the  different  plants  to  install  safety 
engineers  and  are  constantly  co-operating  with  these  to  prevent 
accidents. 

Likewise,  sanitary  inspections  of  the  plants  are  made  by  these 
physicians.  Since  one  of  them  is  a  member  of  the  City  Board  of 
Health,  unsanitary  conditions  in  the  community  surrounding  the 
plants  are  carefully  investigated  and  corrected. 

Recently  they  have  extended  their  health  supervision  to  include 
physical  examinations  of  employees.  As  their  work  grows  it  will 
become  necessary  to  double  and  triple  their  staffs. 


THE    MEDICAL    STAFF  49 

Such  an  arrangement  as  this  is  ideal  in  many  respects.  Every 
industry  in  a  city  should  co-operate  to  secure  some  such  central  plan 
which  includes  every  branch  of  preventive  medicine  when  they  cannot 
develop  their  own  medical  department.  By  insisting  upon  the 
physical  examination  of  every  applicant  for  work  and  by  periodical 
medical  examinations  of  their  old  forces,  a  card  index  of  the 
physical  condition  of  every  employee  would  soon  be  filed  in  the 
central  office. 

Vaccinations,  typhoid  inoculations  and  other  preventive  measures 
could  be  included  in  the  work.  Then  by  following  up  every  case  of 
sickness  by  a  large,  competent  staff  of  visiting  nurses  communicable 
disease  could  soon  be  controlled. 

Doctors  employed  for  the  sole  purpose  of  visiting  sick  employees, 
without  interfering  with  the  treatment  except  where  definitely  indi- 
cated, but  to  ascertain  that  medical  attention  has  been  sought  and  is 
being  given,  would  reduce  the  length  of  sickness  and  therefore  time- 
loss  to  a  marked  degree. 

Such  a  system  would  have  wonderful  influence  over  the  public 
health  of  the  community,  would  raise  the  standards  of  medical  and 
surgical  practices  in  the  city,  and  by  having  a  central  office  would  ob- 
viate much  duplication  of  work. 

Who  should  be  more  interested  in  the  health  of  the  community 
than  the  industries  employing  the  people  of  that  community?  There- 
fore such  a  co-operative  plan  is  logical  and  results  in  benefits  to  both 
the  employer  and  employee. 

VI.  Complete  Medical  and  Surgical  Care  for  the  Employees  and 
Their  Families. — For  many  years  large  mines  in  the  West,  and  a  few 
railroads,  have  had  arrangements  with  their  medical  staffs  whereby 
for  a  stipulated  sum,  usually  one  dollar  per  month,  the  employee 
and  his  family  can  receive  free  medical  and  surgical  treatment  at 
any  time.  Some  of  these  have  developed  large  hospitals  and  render 
excellent  medical  care  to  their  sick.  Practically  all  these  systems 
employ  entirely  too  small  a  staff  of  physicians.  The  doctors  are  busy 
day  and  night  caring  for  the  sick  and  injured  and  can  give  very  little 
time  to  devel'oping  preventive  medicine  and  health  supervision.  In 
recent  years,  however,  some  of  these  concerns  have  turned  their  atten- 
tion to  this  more  humane  work.  Nowhere  could  a  more  ideal  system 
of  industrial  medicine  and  surgery  be  evolved  than  in  these  mining 
communities  and  railroad  systems  with  their  extensive  hospital 
arrangements. 

One  large  street  railway  corporation  has  extended  its  health  and 
safety  work  to  include  free  medical  and  surgical  care  for  its  employees 
and  their  families.  There  is  no  cost  whatever  to  the  workman  for 
this  service.     They  have  figures  showing  that  the  reduction  in  time 

4 


50  INDUSTRIAL   MEDICINE    AND    SURGERY 

lost  due  to  immediate  and  competent  medical  care  more  than  offsets 
the  expense  of  this  work. 

A  great  many  concerns  employing  from  1000  to  10,000  people 
have  established  in  their  plants  well-equipped  doctor's  offices.  They 
have  retained  their  old  company  surgeon  whose  sole  idea  of  the  work 
is  the  dressing  of  injured  cases,  or  they  have  put  an  untrained  man  in 
charge  on  an  inadequate  salary.  Such  concerns  wonder  why  their 
medical  departments  are  so  expensive  and  why  they  do  not  obtain  the 
results  so  glowingly  spoken  of  by  other  establishments. 

One  of  these  industries,  a  most  progressive  automobile  factory, 
built  a  beautiful  medical  dispensary.  They  retained  their  old  company 
surgeon  just  to  do  their  surgical  work  and  sought  a  younger  man  to 
take  charge  of  the  medical  work  and  supervision  of  the  health  of  their 
employees.  I  was  asked  to  recommend  a  suitably  trained  physician 
and  sent  in  names  of  four  men  trained  in  the  Industrial  Medical  Clinic 
of  Rush  Medical  College.  These  men  all  refused  the  job  because  the 
concern  asked  them  to  give  their  full  time  to  the  work  for  one  hundred 
and  fifty  dollars  per  month.  They  finally  secured  the  services  of  a 
man  for  such  a  salary.  In  six  months  they  let  him  go.  Another  man 
was  employed  for  a  similar  salary.  His  requests  for  assistants  and 
nurses  were  not  granted  for  reasons  quite  obvious  considering  the  initial 
pay  for  the  chief  of  staff.  This  concern  is  not  at  all  enthusiastic  over 
the  results  of  industrial  medicine  and  surgery. 

No  individual  proprietor,  president  of  a  corporation,  board  of 
directors,  or  anyone  else  in  authority  should  contemplate  introducing 
a  comprehensive  system  of  medical  and  surgical  work  among  their 
employees  without  being  willing  to  stand  an  initial  outlay  of  money 
far  in  excess  of  what  can  actually  be  shown  in  dollars  and  cents  as  a 
monetary  gain  to  them  for  such  work.  They  must  first  see  the  vision 
of  what  lies  within  their  power  to  do  for  human  conservation.  They 
must  first  be  imbued  with  a  great  desire  to  see  the  working  home  of 
their  people  a  healthful,  sanitary  place,  with  protection  of  every  kind 
for  both  life  and  limb.  Then  the  happier,  contented  working  force,  the 
healthier,  more  efficient  employees,  the  reduction  in  "time-loss" 
from  sickness  and  accidents,  the  decrease  in  "hiring  and  firing," 
the  ever  increasing  loyalty  and  experience  of  old  hands,  these  and  many 
other  by-products  from  such  a  system  will  be  theirs  to  place  in  the 
credit  column. 

"But  how  much  money  can  we  credit  to  these?"  Who  knows! 
Many  a  good  man  has  tried  to  estimate  the  value  of  this  work  in  dol- 
lars and  cents  but  has  always  failed. 

Rest  assured,  Mr.  Employer,  that  the  increased  productivity  will 
pay  far  in  excess  of  outlay  for  such  protection. 


CHAPTER  IV 
THE  NURSE  IN  INDUSTRY 

Industrial  nursing,  like  industrial  medicine,  has  developed  into 
a  new  specialty  in  the  medical  field.  These  nurses  are  absolutely- 
essential  in  any  comprehensive  plan  for  the  supervision  of  the  health 
of  employees. 

The  successful  industrial  nurse  must  have  a  strong  and  likable 
personality,  a  well-developed  social  sense,  leavened  with  much  common 
sense,  and  a  creative  instinct  which  will  enable  her  to  devise  new  meth- 
ods of  increasing  the  scope  of  her  work.  It  is  impossible  to  outline  the 
exact  duties  which  the  nurse  in  industry  must  perform  for  new  duties 
and  new  methods  of  approaching  them  are  constantly  arising.  No 
nurse's  training  school  can  fit  a  nurse  for  this  special  work  but  she 
must  learn  it  by  actual  experience  in  the  field.  At  present  it  is  planned 
to  start  an  industrial  course  in  Chicago  which  will  enable  these  girls 
to  obtain  an  interneship,  as  it  were,  in  some  of  the  large  industrial  dis- 
pensaries. Such  a  plan  would  greatly  increase  the  effectiveness  of 
the  work  of  the  human  maintenance  departments  in  industry. 

Miss  Mae  Middleton,  one  of  the  most  prominent  industrial  nurses 
in  this  country,  has  written  the  following  article  for  this  book.  Her 
experience,  extending  over  a  period  of  several  years,  enables  her  to 
speak  authoritatively  on  this  subject. 

"Although  Industrial  Nursing,  as  we  know  it,  is  a  comparatively 
new  branch  of  Public  Health  work,  it  is  at  least  twenty  years  since 
industries  began  to  realize  the  necessity  of  having  medical  and  nursing 
service,  especially  where  a  large  number  of  people  was  employed  and 
where  the  work  was  hazardous. 

"At  first  this  work  was  confined  to  emergencies  only  and  was  en- 
trusted to  the  care  of  a  man  who  had  received  some  instruction  in 
First  Aid,  or  to  the  so-called  nurse,  who  frequently  had  little  or  no 
training;  the  graduate  nurse  was  seldom  employed. 

'The  benefits  to  be  derived  from  well  organized  medical  and  nurs- 
ing service,  conducted  by  professional  workers,  had  not  yet  been  rec- 
ognized or  demonstrated  in  the  business  world,  although  it  had  been 
thought  out  and  applied  in  relation  to  the  community  by  many  earnest 
civic  students  and  workers.  Facts  revealed  by  comparatively  recent 
and  intensive  studies  in  social  and  economic  conditions,  as  well  as  the 
obligations  imposed  by  employers'  liability  laws,  have  led  employers 

51 


52  INDUSTRIAL    MEDICINE    AND    SURGERY 

to  recognize  it  as  a  very  important  asset  in  the  prevention  of  disease 
and  accident,  and  in  the  preservation  of  the  health  and  efficiency 
of  the  employee ;  it  is  also  of  great  value  in  creating  a  spirit  of 
loyalty  and  contentment  among  the  employees,  where,  for  various 
reasons,  it  was  often  sadly  lacking  or  non-existent — so  that  now  the 
employers  seek,  for  the  management  of  their  medical  departments, 
the  expert  physician  or  surgeon  and  the  graduate  nurse  with  special 
social  service  training. 

''The  medical  and  nursing  service  of  a  large  plant  is  responsible 
for  maintaining  the  health  of  the  employees  to  the  highest  point  of 
efficiency  possible,  in  order  that  the  firm  may  receive  for  the.  services 
of  this  department  adequate  compensatory  returns  in  the  form  of 
less  time  lost,  fewer  accidents,  and  better  sanitary  conditions — with 
the  result  that  there  is  a  better  quality  of  work  done  by  the  employees, 
and  an  increased  output. 

"The  hospital  department,  with  its  staff,  in  addition  to  the  healing 
of  disease  and  alleviation  of  pain,  is  ever  on  the  look-out  for  sources, 
causes,  and  conditions  from  which  they  may  arise,  and  must  engage 
in  study  and  effort,  in  co-operation  with  other  departments  and  or- 
ganizations for  their  cure  and  removal,  as,  for  instance,  in  the  case  of 
Mr.  S. 

'*Mr.  S.,  employed  as  porter,  was  usually  a  very  industrious  and  good 
employee,  but,  owing  to  the  frequent  illness  of  his  children,  he  became 
absent-minded,  worried  and  very  much  run-down.  The  first  call  by 
the  nurse  was  made  at  his  home  July  28,  1917.  The  nurse  found  five 
children,  ages  eleven,  eight,  five,  and  two  years,  and  a  baby  four 
months  old.  All  the  children  appeared  undernourished.  The  family 
lived  in  a  four  room  basement  flat,  poorly  ventilated  but  fairly  clean. 
The  mother  seemed  to  have  no  conception  as  to  the  proper  food  for  the 
children,  the  two-year-old  eating  as  many  as  10  bananas  in  one  day. 
Little  Joe,  the  four-months  baby,  was  very  ill,  and  though  the  ther- 
mometer registered  nearly  90  degrees,  the  poor  little  fellow  was  tightly 
bound  up  in  a  feather  pillow.  There  were  no  screens  on  the  windows, 
and  the  place  was  just  swarming  with  flies.  The  baby  was  given  a 
cool  bath  immediately  (he  had  a  temperature  of  103)  and  made 
comfortable. 

"On  July  30th  the  nurse  called  again  and  brought  the  baby  in  to 
one  of  the  house  physicians,  who  makes  a  specialty  of  infant  feeding. 
The  doctor  examined  the  baby  thoroughly  and  said  that,  although 
the  baby  was  very  ill,  he  would  pull  through  with  proper  care.  The 
mother  and  baby  were  sent  home  in  a  cab,  owing  to  the  extreme  heat, 
and  the  nurse  followed  soon  after,  with  nursing  bottles,  nipples,  a 
small  kettle,  and  everything  needed  for  preparing  infants'  food.  She 
taught  the  mother  every  detail  in  regard  to  the  sterilization  of  bottles, 


THE    NURSE    IN    INDUSTRY  53 

the  care  of  milk,  etc.,  but  they  had  no  ice.  This  great  need  was  ex- 
plained to  the  welfare  department,  and  the  nurse  was  given  a  check 
to  purchase  an  ice-box.  In  less  than  one  hour  the  ice-box  was  in- 
stalled. The  mother  was  also  taught  the  proper  method  of  bathing 
the  baby,  and  the  two-year-old  child  was  put  on  a  diet. 

"On  her  next  call,  August  1st,  the  nurse  found  the  baby  much  im- 
proved; the  mother  carrying  out  instructions  to  the  letter.  The 
landlord  had  put  screens  in  the  windows,  and  there  were  no  flies  this 
day.  Also,  the  department  manager  reported  that  Mr.  S.  was  doing 
much  better,  taking  more  interest  in  his  work,  and  looking  better. 

"When  again  examined  by  the  doctor,  August  6th,  the  baby  was 
found  to  have  gained  ^  pound,  and  its  diet  was  increased. 

"By  this  time  all  the  children  seemed  better.  The  nurse  called 
every  other  day  for  a  while,  and  the  baby  continued  to  improve. 
Later,  owing  to  the  busy  season,  the  nurse  was  unable  to  call  so  often, 
but  she  left  word  with  the  family  to  report  any  change.  Then 
some  neighbor  suggested  that  they  give  the  baby  tea,  and  he  became 
very  ill.  The  nurse  again  called  every  day  and  gave  the  baby  care, 
but  he  did  not  improve  and  later  died. 

"However,  the  work  was  well  worth  while,  for  the  change  in  the 
rest  of  the  family  was  wonderful.  In  place  of  coffee  and  buns  every 
morning  and  noon,  they  now  have  cereals,  vegetables,  etc.,  and  in 
consequence  Mr.  S.,  as  well  as  the  children,  is  better  nourished  and 
happier. 

"The  daily  routine  of  the  nurses  department  involves: 

"Assisting  the  doctors  in  the  examination  of  employees  return- 
ing to  work  after  absence  on  account  of  illness. 

"Assisting  in  the  dressings  of  surgical  cases. 

"Administering  to  the  employees  sent  to  the  rest  rooms. 

"Calling  of  all  employees  who,  at  the  doctors'  request,  have  been 
scheduled  for  re-examination. 

"Assisting  in  the  examination  of  new  employees  and  those 
desiring  to  join  the  benefit  association. 

"Assisting  in  the  examination  of  those  sent  from  their  depart- 
ments for  examination  because  of  frequent  absence  or 
inability  to  keep  up  with  their  work. 

"Assisting  in  the  care  of  relatives  of  employees,  who,  on  account 
■  of  financial  conditions,  are  unable  to  obtain  medical  or 
hospital  care. 

"Visiting  sick  employees  in  their  homes. 

"The  nurses  answer  calls  made  by  the  departments  on  all  emergency 
and  accident  cases  which  are  of  such  serious  nature  that  they  are  un- 
able to  come  to  the  doctor's  office  alone  and  must  be  brought  by  means 


54  INDUSTRIAL   MEDICINE    AND    SURGERY 

of  wheel  chairs  or  stretchers.  Many  of  these  cases  are  temporary 
conditions,  such  as  dysmenorrhea,  faints,  headaches,  etc.,  and  after 
rest  and  care  are  frequently  able  to  return  to  their  work. 

"The  routine  examinations,  however,  often  disclose  cases  of  acute 
infection,  such  as  typhoid,  pneumonia,  or  those  requiring  surgical  care. 
Provision  is  made  for  the  care  of  these  employees  in  hospitals,  sanatoria, 
homes  or  other  institutions,  through  co-operation  with  the  welfare 
department,  the  family,  and  the  family  physician.  In  urgent  cases, 
requiring  immediate  hospital  care,  the  family  and  their  physician  (if 
they  have  one)  are  reached  by  telephone.  This  is  followed  by  a  call 
from  the  nurse,  in  order  to  assure  the  patient,  who  is  usually  concerned 
about  conditions  at  home,  and  to  allay  the  fears  of  relatives,  as  in  the 
case  of  Mr  R.,  who  was  sent  to  the  doctor's  office  because  he  com- 
plained of  pain  in  the  right  arm.  He  was  examined  and  sent  to  the 
hospital  with  a  diagnosis  of  cellulitis. 

"The  nurse  called  at  his  home,  to  tell  his  wife,  and  found  he  had  two 
children,  one  23=^^  years  and  one  nine  months  old.  The  oldest  child 
had  a  temperature  of  103.4,  axillary,  and  was  in  a  comatose  condition; 
the  other  child  had  a  temperature  of  102.6,  a  sore  throat  and  rash. 
The  mother  herself  had  a  temperature  of  99.8  and  was  tired  out,  as 
she  had  had  no  sleep  for  three  nights.  The  nurse  immediately  gave 
both  children  sponge  baths,  to  reduce  their  temperatures,  prepared 
milk  for  them  and  instructed  the  mother  how  to  give  them  the  neces- 
sary care.  She  then  returned  to  the  plant  and  reported  the  case  to 
one  of  the  company  physicians,  who  was  also  an  infant  welfare  special- 
ist, and  he  went  with  her  to  the  home  to  see  the  children.  After 
prescribing  treatment,  he  advised  putting  on  a  special  nurse  for  one 
week.  Through  co-operation  with  the  welfare  department  this  was 
done,  the  firm  paying  for  the  nurse.  At  the  end  of  the  week  both 
children  were  so  much  improved  that  the  nurse  left.  However,  a 
week  later  the  older  child  became  very  ill  again  with  a  discharging  ear 
and  an  enlarged  cervical  gland,  so  the  nurse  brought  him  in  to  the 
doctor's  office^  where  the  gland  was  opened.  As  this  required  subse- 
quent dressings,  the  nurse  called  daily,  making  25  calls  in  all  on  the 
child,  besides  frequent  visits  to  the  hospital  to  let  the  child's  father 
know  of  his  condition. 

"The  man  is  now  back  at  work,  his  wife  and  children  are  in  good 
health  and  all  are  very  grateful  to  the  firm  for  the  interest  shown  and 
aid  given. 

"The  following  illustrates  the  daily  routine  of  the  nurses  at  the  plant 
and  in  the  homes. 

"Usually  morning  duty  is  in  the  hospital.  Possibly  the  first  patient 
complains  of  headache.  The  temperature  is  taken  and  found  normal, 
as  is  also  the  pulse;  nothing  abnormal  about  the  throat.     The  patient 


THE   NURSE    IN    INDUSTRY  55 

is  taken  to  the  doctor  who  prescribes  aspirin  or  Seidhtz  powder,  and 
is  then  allowed  to  go  to  the  rest  rooms  and  lie  down  until  better  and 
feeUng  able  to  return  to  his  department. 

"Perhaps  the  next  patient  coming  in  complains  of  stomach  trouble, 
wishes  to  see  the  doctor  and  to  have  a  thorough  examination.  He  is 
very  fearful  of  an  ulcer  of  the  stomach.  He  was  not  able  to  retain  any 
of  his  dinner  the  night  before;  had  just  a  'common  dinner,'  consisting 
of  pork,  cabbage,  potatoes,  jelly  cake  and  tea.  This  patient  is  referred 
at  once  to  the  doctor. 

"Last,  but  not  least,  comes  a  new  employee,  who  must  have  height, 
weight,  pulse,  temperature,  eye-test,  personal  and  family  history  taken. 
He  is  asked  to  please  take  off  his  wraps  and  hang  them  on  the  back  of 
the  chair.  From  the  effort  he  makes  to  find  a  chair  in  the  next  room, 
ignoring  the  one  pointed  out  to  him,  and  from  his  answer,  'Leedle  bidt, 
missus — -not  so  much/  to  the  very  common  question,  'Do  you  speak 
English,  mister?,'  the  nurse  is  prepared  for  almost  any  sort  of  answers 
to  her  questions. 

"  'When  were  you  vaccinated?' 

"  'Vacci-?     Vacci-?     Me  no  understand,  missus.' 

"  'When  did  the  doctor  scratch  your  arm  and  put  medicine  in  it?' 
The  part  of  the  arm  is  indicated. 

"  'No,  sir.     Me  no  got  scratched.' 

"  'How  many  years  have  you  been  in  America,  Mister?' 

"  'Four  years — maybe  five,  all  right.' 

"  'When  you  came  over  on  the  boat,  didn't  the  doctor  on  the  boat 
scratch  your  arm  and  put  medicine  in  it?' 

"A  look  of  understanding  dawns.  He  smiles  and  says,  "Yes,  sir. 
Me  got  it.' 

"Then,  'Do  you  read  English,  mister?' 

"  'Leedle  bidt,  all  right.' 

"  'See  that  card  hanging  out  there,  with  the  letters  on  it?' 

"  'Yes,  sir.' 

"  'See  the  red  Hne?' 

"  'Yes,  sir.' 

"  'Will  you  please  read  the  letters  on  it?' 

"This  is  done,  and,  to  be  sure  the  letters  have  not  been  memorized 
while  he  has  been  awaiting  his  turn,  the  nurse  says,  '  All  right.  Now 
read  them  backward,  with  your  left  eye.'  -She  places  a  shield  over  the 
right  eye  and  wonders  why  the  man  gets  up  and  slowly  turns  around, 
putting  his  knee  on  the  chair  and  craning  his  neck  over  his  shoulder ; 
then  it  dawns  upon  her  that  he  is  really  trying  his  best  to  read  them 
'backward.' 

"So  it  goes  through  the  morning — with  variations. 


56  INDUSTRIAL    MEDICINE    AND    SURGERY 

"In  the  afternoon  the  nurse  takes  a  list  of  the  absent  employees  in 
her  district  and  tries  to  visit  as  many  as  she  can. 

"Call  No.  1. — Possibly  this  takes  her  to  a  neighborhood  with  which 
she  is  not  familiar.  She  asks  a  youngster,  'Is  this  N.  Place?' 
and  receives  the  following  answer:  'Naw,  this  ain't  it.  This  is  N. 
Avenue.     Go  down  this  way  and  jerk  over,  and  that's  it.' 

"She  finds  the  street  and  number  and  learns  that  her  patient  lives 
on  the  third  floor.  When  she  inquires  for  her,  she  is  told,  '  No,  she 
isn't  in  just  now.  She  hasn't  been  feeling  well,  but  is  better  to-day, 
so  went  for  a  walk.'  The  nurse  is  very  glad  to  know  that  the  patient 
is  feeling  better  and  'Will  she  please  report  at  the  Doctor's  Office 
in  the  morning?' 

"  Call  No.  2. — On  this  call  she  finds  her  patient  quite  ill  with  a  cold 
and  sore  throat.  He  is  subject  to  two  or  three  similar  attacks  during 
a  winter.  The  tongue  is  badly  coated;  tonsils  are  very  much  enlarged, 
with  very  small,  white  patches.  She  inquires  if  the  patient  is  under 
the  care  of  a  doctor.  'No.  He  has  been  taking  hot  drinks  and  used 
a  gargle  prescribed  for  the  last  attack,  but  hasn't  any  more  left.' 
The  patient  is  advised  to  take  a  cathartic,  preferably  castor  oil;  to 
gargle  the  throat  with  a  hot  solution  of  baking  soda  every  two  or  three 
hours — a  teaspoonful  to  a  glass  of  water;  to  drink  as  much  water  as 
possible;  to  get  plenty  of  fresh  air;  to  keep  his  dishes  separate  from 
those  used  by  the  other  members  of  the  family;  and  to  be  very 
careful  of  excretion  from  the  throat  and  nose.  If  not  better  by  noon, 
he  is  told  to  call  his  family  doctor,  and  last,  but  not  least,  to  see  his 
own  doctor  or  the  doctor  at  the  plant  as  to  advice  about  tonsillectomy. 
In  two  days  the  employee  reports,  wishing  to  return  to  work,  and  is 
referred  to  the  doctor. 

"  Call  No.  3. — This  patient  is  found  to  be  very  ill.  He  has  had  a 
stroke  of  paralysis,  involving  the  entire  right  side,  several  days  ago. 
He  is  in  a  semicomatose  condition,  and  has  just  been  made  comfortable 
by  a  practical  nurse,  who  is  a  relative.  Evidently  there  is  nothing  that 
can  be  done  for  the  patient  at  this  time.  The  nurse  tells  the  wife  that 
if  there  is  anything  she  can  do,  she  will  be  very  glad  to  do  it.  The  wife 
replies,  'No,  there  isn't  anything  to-day.' 
"  '  Very  well,  I'll  call  again  tomorrow.' 

"  On  revisit,  the  following  day,  the  patient's  condition  is  apparently 
the  same.  The  pulse  seems  of  a  fairly  good  quality,  slightly  irregular; 
respirations  seem  to  be  Cheyne-Stokes  type.  The  patient  has  been 
lying  on  a  davenport,  and  his  wife  is  very  anxious  to  have  him  moved 
to  the  bed,  but  the  nurse  (at  the  home)  is  not  feeling  well  and,  '  Will 
you  please  help?'  The  wife  is  asked  if  she  has  the  doctor's  permission 
to  move  the  patient  and  she  says,  '  Yes,  he  thought  it  a  very  good  idea.' 
The  nurse  suggests  the  placing  of  the  bed,  so  the  best  light  and  venti- 


THE    NURSE    IN    INDUSTRY  57 

lation  are  obtained.  The  bed  is  made  up  with  an  oilcloth  protector 
and  draw  sheet,  and  instructions  are  given  as  to  how  to  remove  the 
sheet  with  least  discomfort  to  the  patient.  Blankets  are  placed  in 
readiness  to  place  the  patient  between  for  a  bath.  Fellow  employees 
soon  come  to  help  move  the  patient  to  the  bed.  His  condition  does  not 
seem  any  worse  because  of  having  been  moved,  and  he  is  allowed  to 
rest  for  a  short  time  before  given  the  bath.  A  sponge  bath  and  alcohol 
rub  are  given,  and  the  patient  is  made  as  comfortable  as  possible. 
The  bedding  is  adjusted  so  that  the  weight  will  not  he  too  much  on 
the  extremities,  and  the  wife  is  told  that  if  help  is  needed  again,  the 
nurse  will  be  very  glad  to  come. 

"  In  the  meantime,  some  observing  forelady  at  the  plant  has  noticed 
the  condition  of  the  head  of  one  of  her  employees  and  has  sent  her  to 
the  hospital.  The  girl's  head  is  inspected  by  one  of  the  nurses  and 
found  to  be  in  need  of  treatment  at  once.  It  is  necessary  to  cut  some 
of  the  hair  and  apply  ointment  to  the  scalp  where  the  skin  has  been 
scratched,  and  the  first  of  a  series  of  treatments  is  given.  The  girl 
is  sent  home  and  told  to  leave  her  head  just  as  it  is;  that  a  nurse  will 
call  in  the  morning  to  give  another  treatment. 

"  In  the  morning  the  nurse,  armed  with  gown,  gloves,  tooth  picks 
and  ointment,  makes  the  promised  call.  She  finds  that  there  is  no 
kerosene  in  the  house  and  has  to  wait  until  someone  goes  out  to  buy 
some.  There  is  quite  an  improvement  in  the  condition  of  the  head. 
After  all  her  articles  are  laid  in  readiness,  the  nurse  proceeds  to  relieve 
the  head  of  as  much  vermin  as  she  can,  then  applies  more  ointment  to 
abrased  area,  saturates  the  hair  with  equal  parts  of  olive  oil  and  kero- 
sene, and  ties  up  the  head,  with  instructions  to  leave  it  that  way  for 
four  or  five  hours,  then  to  fine  comb  the  hair  and  wash  with  warm 
water  and  soap,  and,  when  nearly  dry,  to  apply  hot  vinegar  and  use  the 
fine  comb  again.  This  treatment  is  to  be  continued  for  two  more  days; 
then  the  girl  is  to  report  at  the  hospital.  Before  leaving  the  home, 
the  nurse  makes  sure  that  the  rest  of  the  family  is  going  to  be  taken 
care  of  in  the  same  way,  if  necessary. 

"  In  all  of  the  examinations  made  at  the  hospital,  the  nurse  can  be 
of  great  assistance  to  the  company  physician  by  conserving  his  time 
and  preventing  duplication  of  work.  As  it  is  impossible  for  the  physi- 
cian to  see  all  cases  coming  to  the  doctor's  office,  it  is  the  duty  of  the 
nurse  to  select  only  such  cases  as  it  is  absolutely  necessary  for  him  to 
see.     The  nurse  should  make  sure: 

"First. — That  the  physician  has  all  the  data  concerning  patient's 
home,  financial  and  working  conditions. 

"  Second. — That  he  has  a  complete  record  of  all  previous  medical, 
surgical  or  dental  examinations;  also  any  family  medical  history 
that  might  aid  him  in  making  his  diagnosis  and  in  recommending  such 


58  INDUSTRIAL    MEDICINE    AND    SURGERY 

disposition  of  the  case  as  would  be  to  best  advantage  of  both  the 
employee  and  his  employers. 

"In  well-organized  medical  departments  of  large  concerns,  one  nurse 
is  usually  assigned  to  follow  up  tuberculous  cases  only.  It  is  not  just 
the  case  of  the  tuberculous  employee;  the  whole  family  must  be  ex- 
amined for  possible  infected  contacts;  home  conditions  must  be  looked 
into  and  changed,  if  necessary,  and  the  family  instructed  as  to  home 
and  personal  hygiene.     The  home  of  Mr.  0.  is  a  case  in  point. 

"Mr.  0.,  who  had  been  placed  in  a  sanatorium,  wrote  as  follows: 

'  I  desire  to  inform  you  that  on  Tuesday,  September  25th,  I  left  the  F.  A. 
Hospital  and  came  home,  after  spending  15  months  in  the  institution.  For  the 
past  three  months  I  have  been  confined  to  bed  because  of  high  fever,  so  I  decided 
that  as  my  progress  was  none,  it  was  as  advantageous  to  come  home  as  remain 
in  the  institution,  since  there,  I  must  confess,  improvement  is  rather  slight. 

'in  conclusion,  I  will  say  that  I  am  very  grateful  to  S.,  R.  and  Co.  for  the  effort 
put  forth  in  bringing  about  my  recovery,  also  I  am  highly  pleased  with  the  medical 
department  for  the  kindness  shown  on  all  occasions.' 

"A  few  days  after  his  return  home,  the  company  physician  and  nurse 
were  called  and  found  the  patient  had  developed  a  discharging  right 
pyothorax,  necessitating  his  return  to  bed.  The  nurse  made  daily 
calls  to  dress  the  wound  and  give  bedside  care. 

"The  efforts  of  the  nurse  to  instruct  Mrs.  O.  will  best  illustrate  the 
difficulties  encountered  in  attempting  this  hygienic  education. 

"Mrs.  0.  seemed  to  think  that  the  care  given  by  the  nurse  was  suffi- 
cient, and  it  seemed  almost  impossible  to  make  her  realize  that  Mr.  0. 
should  be  bathed  frequently,  and  that  the  bed  should  be  kept  neat 
and  clean.  After  explaining  in  detail  just  what  to  do,  to  make  Mr.  0. 
comfortable,  the  nurse  would  be  answeted  in  the  following  manner : 

"  'Sure,  whin  he  do  be  in  good  hilth,  he  always  washed  his  face  and 
hands  ivery  mornin'  before  goin'  to  woork.  He  always  looked  so 
nice  the  neighbors  often  wundered  how  he  could  git  out  of  this  dirty 
hole  lookin'  so  foine.  Nurse,  I  don't  think  it  would  be  nicessary  to 
wash  him  ivery  day  now.  He  never  shwits.  Sure,  he  could  wear  a 
pair  of  socks  for  a  long  toime  and  they  do  be  niver  shtiff  with  the  dirt.' 

"As  it  seemed  impossible  to  persuade  Mrs.  0.  to  give  the  patient 
proper  care,  he  was  induced  to  return  to  the  sanatorium,  where  he 
now  is. 

"Qualifications  of  the  Industrial  Nurse.^ — The  nurse  intending  to 
take  up  industrial  work  should  have  as  her  foundation  training  in  a 
good  general  hospital,  and,  in  addition  to  this,  some  experience  in 
other  forms  of  public  health  nursing,  as  this  is  almost  as  essential. 
She  should  be  in  good  physical  condition;  have  patience,  tact  and 
sympathy,  acting  as  the  employer's  representative,  both  at  the  plant 
and  in  the  home,  in  bringing  aid  and  comfort  to  his  injured  or  sick 


THE    NURSE    IN    INDUSTRY  59 

employee;  she  must  have  insight  and  wisdom,  in  order  to  interpret 
correctly  the  employer  to  the  employee,  and  vice  versa. 

"In  the  last  five  or  six  years  much  has  been  done  in  the  field  of  in- 
dustrial nursing,  and  many  nurses  have  taken  up  this  work.  About  13^^ 
years  ago  the  Chicago  Industrial  Nurses  Club  was  organized,  and  it 
now  has  an  enrolled  membership  of  between  65  and  70  nurses,  all  of 
whom  are  employed  in  industries  in  Chicago.  While  this  shows 
clearly  the  possibilities  of  the  future  development  of  this  branch  of 
public  health  work,  as  yet  it  has  simply  cleared  the  way  to  larger 
horizons,  and  it  is  to  the  industrial  nurse  of  to-day  that  we  must  look 
to  create  the  standard  for  industrial  nursing.  To  her  is  given  the 
opportunity  to  make  the  work  so  valuable,  not  only  to  the  employee, 
but  to  the  employer,  that  she  will  be  considered  an  integral  part  of 
any  plans  made  by  him  for  the  health  and  welfare  of  his  employees.'* 


CHAPTER  V 
EMPLOYEES  DENTAL  SERVICE 

The  medical  and  surgical  dispensary  in  industry  is  not  considered 
complete  unless  it  provides  some  form  of  dental  service  for  the  em- 
ployees. For  several  years  a  number  of  our  best  industrial  clinics 
have  included  dentists  on  their  staffs.  In  this  respect  they  have 
taken  a  more  advanced  scientific  position  than  the  majority  of  our 
medica'  dispensaries  connected  with  medical  colleges. 

During  the  last  ten  years  Billings,  Rosenow,  Davis,  Dick  and  many 
other  investigators  have  absolutely  proven  that  foci  of  infection  hid- 
den in  different  parts  of  the  body  are  the  actual  cause  of  many  on- 
stitutional  diseases.  The  commonest  sites  for  hidden  infection  are 
about  the  teeth.  As  a  result,  the  medical  profession  now  includes  a 
careful  examination  of  the  teeth  as  a  definite  part  of  the  systematic 
physical  examination  of  the  patient.  Closer  co-operation  with  the 
dentist  has  been  established  and  just  as  the  internist  refers  his 
gall-bladder  and  diseased  appendix  cases  to  the  surgeon  for  operation, 
so  he  refers  his  patients  with  infected  mouths  to  the  dentist  for  treat- 
ment. The  x-ray  has  become  the  most  valued  ally  of  both  the  doc- 
tor and  the  dentist  in  discovering  these  foci  of  infection  about  the 
teeth. 

Physicians  and  surgeons  connected  with  industries  were  among 
the  first  to  recognize  the  great  economic  value  of  properly  supervis- 
ing and  caring  for  the  employee's  teeth.  These  men  who  had  advanced 
industrial  sanitation  to  such  an  extent  now  realized  that  the  same 
laws  of  sanitation  must  be  applied  to  the  individuals.  The  work  of 
the  dentist  in  industry  is  quite  analogous  to  that  of  the  sanitary  in- 
spector. His  inspections,  however,  are  limited  to  the  employees' 
mouths  and  his  corrective  measures  are  directed  to  cleaning  up  the 
dirty  teeth.  No  medical  school  of  to-day  which  prides  itself  upon  its 
efforts  to  teach  preventive  medicine  can  longer  afford  to  neglect  the 
establishment  of  a  dental  department  in  its  dispensary. 

During  the  year  prior  to  the  establishment  of  a  dental  clinic  in  the 
concern  with  which  the  author  was  connected,  1100  employees  re- 
ported to  the  doctor's  oflice  on  account  of  toothache,  abscessed  teeth, 
or  some  other  condition  traceable  directly  to  the  teeth.  It  was 
necessary  to  send  many  of  these  employees  to  an  outside  dentist  for 
emergency  treatment.     Because  of  the  lack  of  adequate  supervision  of 

60 


EMPLOYEES    DENTAL    SERVICE  61 

these  cases,  many  of  them  were  satisfied  with  the  immediate  reHef 
and  failed  to  continue  the  treatment  until  permanent  relief  was 
obtained.  Naturally  recurrences  were  common  and  such  employees 
lost  considerable  time  from  work.  Even  if  no  actual  time  away 
from  the  plant  was  lost,  yet  a  workman  with  a  toothache  has  a  very 
questionable  efficiency.  It  was  impossible  to  obtain  actual  figures  as 
to  the  financial  loss  this  concern  was  sustaining  due  to  diseased  teeth 
among  the  workers,  but  sufficient  data  were  collected  to  convince 
the  management  that  a  dental  clinic  would  be  a  great  economy. 

The  prevalence  of  unclean  mouths  among  the  employees  due  to 
decayed  teeth,  pyorrhea,  hidden  abscesses  and  other  like  conditions 
is  shown  by  the  reports  of  the  examinations  of  applicants  for  work 
by  different  surgeons.  Dr.  Irving  Clark  found  that  92  per  cent,  of  all 
applicants  showed  some  diseased  condition  and  this  high  disability 
rate  was  due  chiefly  to  faulty  mouth  conditions.  The  reports  from  my 
clinic  showed  that  approximately  90  per  cent,  of  the  applicants  had 
some  dental  defects.  The  Life  Extension  Institute  reports  98  per  cent, 
of  the  people  examined  by  their  doctors  showed  physical  defects  and 
practically  all  of  these  were  due  to  diseased  conditions  of  the  mouth 
alone  or  combined  with  other  conditions. 

I  recently  had  the  opportunity  of  examining  16,000  draftees  who 
were  placed  in  "limited  service  class"  because  of  some  physical  dis- 
ability and  were  ordered  to  report  to  Syracuse  Recruit  Camp.  Over 
4000  of  these  young  men  had  been  placed  in  limited  service  because 
of  diseased  teeth  or  because  of  an  insufficient  number  of  teeth.  Approxi- 
mately 500  of  them  had  plates  and  over  200  had  lost  all  of  their  upper 
and  lower  teeth.  Approximately  70  per  cent,  of  the  contingent  sent 
from  the  New  'England  States  had  fine  physiques,  and  their  only 
dsfects  were  due  to  the  teeth,  many  of  these  having  lost  all  of  their 
upper  or  lower  teeth  or  both.  Such  figures  clearly  prove  that  as  a 
nation  we  are  neglecting  the  care  of  the  children's  teeth  and  when  they 
reach  the  age  to  voluntarily  seek  dental  care,  it  is  too  late  and  the 
dentist  is  forced  to  his  last  resort,  namely,  extraction. 

The  above  figures  conclusively  demonstrate  the  prevalence  of 
diseased  teeth.  The  spirit  of  prevention  should  certainly  force  every 
physician  in  industry  to  attack  this  problem  with  renewed  energy 
and  his  greatest  ally  should  be  a  qualified  dentist  working  with  him 
in  the  plant. 

In  1914  I  found  approximately  20  industrial  concerns  were  giving 
some  form  of  dental  service  to  their  employees.  Dr.  Lee  K.  Frankel, 
in  1916,  sent  a  questionnaire  to  several  industries  for  the  purpose  of 
ascertaining  the  number  giving  dental  service  to  employees  and  the 
kind  of  treatment  given.  He  received  replies  from  27  establishments 
all  of  whom  either  employed  dentists  or  had  some  arrangement  with 


62  INDUSTRIAL   MEDICINE    AND    SURGERY 

outside  dentists.  Dr.  Selby  in  his  recent  investigations,  conducted 
by  personal  visits  to  a  great  number  of  industries,  found  that  quite  a 
number  were  paying  considerable  attention  to  the  care  of  the  employees' 
teeth. 

The  various  systems  in  vogue  in  different  industries  can  be  classi- 
fied as  follows: 

1,  Dentists  employed  on  part  or  full  time;  a  fully  equipped  dental 
office  in  connection  with  the  plant;  dental  service  given  to  the  em- 
ployees at  the  company's  expense  and  on  the  company's  time. 

The  dental  service  given  consists  of:  (a)  Examination,  cleaning, 
filling,  bridge,  crown  and  plate  work  and  extraction;  (6)  examination 


Fig.   12. — Tooth-brush    drill    conducted    by  the    company  nurse.      {Colorado  Fuel  & 

Iron  Co.) 

and  cleaning  only,  with  the  necessary  dental  work  performed  by  out- 
side dentists  under  supervision  of  the  plant  dentist;  (c)  examination 
only,  with  supervision  of  the  necessary  dental  work  performed  by  the 
outside  dentist. 

2.  Dentists  employed  by  industries;  a  fully  equipped  dental  ofiice 
in  connection  with  the  plant;  dental  service  given  at  employee's 
expense  but  on  the  company's  time. 

Frankel  found  at  least  six  concerns  operating  under  this  system. 
The  dental  service  given  extends  all  the  way  from  examination  with 
complete  dental  operations  to  examinations  and  cleaning  only.  The 
service  and  the  material  used,  such  as  gold  and  porcelain  crowns, 
material  for  filling,  etc.,  are  furnished  at  cost. 

3.  Arrangements  made  with  outside  dentists,  or  dental  dispensaries, 
to  furnish  dental  service  at  a  reduced  rate  to  the  employees. 

Practically  all  of  the  concerns  using  this  system  have  their  own 


EMPLOYEES    DENTAL    SERVICE  63 

medical  staffs.  The  doctors  examine  the  teeth  at  the  time  of  physical 
examination  of  employees  and  refer  those  needing  dental  service  to 
the  outside  dentist  or  the  dispensary. 

4.  At  least  three  industries  furnish  free  dental  service  to  the 
children  of  employees.  The  visiting  nurses  of  these  concerns  have  been 
thoroughly  trained  in  examining  the  teeth  of  the  children  and  are  in- 
structed to  refer  all  needing  dental  care  to  the  dental  clinic  at  the  plant. 
These  nurses  likewise  give  lectures  to  the  mothers  and  children  on 
dental  hygiene  and  instruct  them  concerning  the  proper  use  of  the 
toothbrush  (Fig.  12). 

Practically  all  of  the  industries  operating  under  the  above  systems 
give  lectures  and  individual  instruction  to  the  employees  concerning 
dental  hygiene.  Some  of  them  furnish  toothbrushes  and  mouth 
washes  at  cost  to  their  people. 

The  equipment  of  the  dental  offices  in  most  places  is  very  complete. 
A  few  concerns  have  even  installed  x-ray  machines  for  radiographic 
examinations.  Those  giving  complete  dental  service  must  naturally 
have  more  chairs  and  more  elaborate  equipment  than  those  simply 
making  examinations,  and  then  supervising  the  treatment  given  by 
outside  dentists. 

Dr.  Frankel's  description  of  the  dental  clinic  at  the  home  office 
of  the  Metropolitan  Life  Insurance  Company,  gives  an  excellent  illus- 
tration of  this  form  of  employee's  service. 

"  The  clinic  was  opened  July  1,  1915.  The  equipment  was  the  best 
obtainable.     It  included: 

''Four  S.  S.  White  Evans-Forsythe  Dental  Units,  which  consists 
of  chair,  bracket,  engine,  cuspidor,  and  compressed  air  attachment. 

"Four  S.  S  White  Lyons  operating  stools. 

"Four  electric  spray  heaters. 

''One  Hitter  Columbia  dental  chair. 

*'One  Ritter  dental  engine. 

''One  electro-dental  switchboard. 

"One  Waugh  radiographic  machine  and  lead  screen. 

"Two  sterilizing  outfits. 

"Four  small  cabinets. 

''One  large  dental  cabinet. 

"One  metal  and  glass  linen  cabinet. 

"Complete  set  of  instruments,  towels,  bibs,  etc. 

"It  was  planned  that  the  work  should  be  limited  to  a  careful  exami- 
nation and  cleansing  of  the  employees'  teeth  each  six  months.  The 
results  of  the  examination  are  charted  and  copies  of  the  charts  are  given 
to  the  employees,  indicating  what  subsequent  treatment  will  be  nec- 
essary by  their  own  dentists. 

"A  follow-up  system  was  inaugurated  to  ascertain  whether  the  neces- 


64  INDUSTRIAL   MEDICINE    AND    SURGERY 

sary  attention  is  given.  No  attempt  was  made  to  require  or  compel 
employees  to  come  to  the  clinic.  From  time  to  time  addresses  were 
delivered  by  the  dentists  in  charge  to  the  employees,  indicating  the 
value  of  proper  care  of  the  teeth. 

"There  are, approximately  5000  employees  in  the  company's  service 
at  the  home  office;  2870  treatments  were  given  to  2707  patients  in 
the  first  six  months,  July  1,  1915,  to  Dec.  20,  1915.  In  the  second 
six  months  3383  treatments  were  given  to  2843  patients.  In  the 
first  six  months  the  average  time  required  for  examination  and  cleansing 
was  approximately  sixty-six  minutes.  With  the  experience  gained 
by  the  dentists  in  charge  this  was  reduced  so  that  in  the  second  six 
months  the  average  time  was  forty-nine  minutes.  The  average  time 
required  is  constantly  decreasing.  Viewed  month  by  month  this  is 
shown  very  clearly.  In  January,  1916,  the  average  time  was  sixty- 
three  minutes,  in  February  fifty-four  minutes,  in  March  fifty-three 
minutes,  in  April  forty-eight  minutes,  in  May  forty-seven  minutes, 
and  in  June  thirty-five  minutes. 

"The  clinic  is  in  charge  of  Dr.  Thaddeus  P.  Hyatt,  who  has  under 
him  four  assistants  and  a  radiographer.  Seven  women  are  employed 
in  the  dental  clinic  as  assistants  to  the  dentists,  as  telephone  operator, 
in  the  sterilizing  room,  etc.  All  the  dentists  are  full-time  employees 
with  the  exception  of  Dr.  Hyatt.  The  service  given  to  the  employees 
is  free  and  on  the  company's  time. 

"I  am  giving  you,  herewith,  the  statistics  for  the  second  six  months, 
namely:  Jan  1,  1916,  to  June  30,  1916,  as  these  are  probably  more 
indicative  than  would  be  those  in  the  first  six  months  of  the  service. 
In  this  time  prophylactic  treatment  was  given  to  2315  patients  and 
emergency  care  to  528  additional  patients,  making  a  total  of  2843 
patients  cared  for  in  the  period.  The  average  time  for  emergency 
cases  twenty-one  and  one-half  minutes.  Under  this  term  is  included : 
treatment  for  abscess,  pyorrhea,  exposed  pulp,  gingivitis,  pulpitis, 
pericementitis,  infected  tooth  socket,  toothache,  and  extractions  and 
consultations. 

"The  cost  of  the  entire  service  was  S7229,  or  an  average  of  S3.00 
per  hour,  and  an  average  per  patient  of  S2.33.  Subdividing  the  pro- 
phylactic work  from  the  emergency  work  the  cost  per  patient  for  the 
former  is  $2.46  and  for  the  emergency  work  the  cost  per  patient  was  $1 .06. 
Assuming  that  employees  accept  service  of  this  kind  each  six  months, 
the  cost  per  treatment  per  patient  per  annum  would,  of  course,  be  dou- 
ble the  figure  given  per  employee  treated. 

"The  results  even  thus  far  obtained  are  of  considerable  interest:  Of 
the  clerks  who  appeared  in  the  first  six  months,  1637  who  showed  cavi- 
ties on  the  first  examination  reappeared  during  the  second  six  months. 
These  clerks  on  the  original  examination  had  7753  cavities  or  an  aver- 


EMPLOYEES    DENTAL    SERVICE  65 

age  of  4.6  cavities  per  person.  During  the  interval  between  the  first 
and  second  examination  916  clerks  (56  per  cent.)  out  of  the  1637 
who  had  cavities  had  2936  fillings  made,  or  an  average  of  3.2  fillings 
per  clerk. 

"There  are  other  evidences  of  improvement  although  they  are  not 
of  such  importance.  At  the  time  of  the  first  examination  3.9  per  cent, 
of  the  clerks  did  not  use  a  toothbrush.  At  the  second  examination  it 
was  found  that  this  had  been  reduced  to  2.9  per  cent.  At  the  time  of 
the  first  examination  32.9  per  cent,  of  the  clerks  did  not  show  clean 
mouths.  At  the  second  examination  only  22.5  per  cent,  showed  such 
condition." 

In  June,  1914  a  dental  department  for  employees  was  established 
in  connection  with  the  doctor's  office  in  a  concern  employing  at  that 


Fig.  13.^ — The  Dental  Office,  an  essential  adjunct  to  the  Industrial  Dispensary. 
{Courtesy  Sears,  Roebuck  &  Co.) 

time  approximately  12,000  people.  The  full-time  service  of  a  dentist 
was  secured  at  first  but  this  was  later  changed  to  the  part-time  service 
plan — one  dentist  spending  four  hours  in  the  morning  at  the  plant  and 
another  dentist  four  hours  in  the  afternoon.  Each  dentist  was  paid 
a  salary  of  $150  a  month  for  this  part-time  service.  The  mistake 
which  many  concerns  have  made  is  in  endeavoring  to  secure  cheap 
dental  service  for  their  employees.  A  reaUy  good  dentist  cannot 
afford  to  give  all  of  his  time  to  an  industry  for  less  than  $300  a  month. 
The  work  of  the  dentists  consisted  in  examining  the  teeth  of  all  appli- 
cants for  work  referred  to  them  by  the  doctors,  whose  duty  it  was  to 
thoroughly  exaniine  the  mouth,  and  to  examine  the  teeth  of  all  old 
employees,  department  after  department,  as  rapidly  as  possible.  Em- 
ployees needing  dental  care  were  furnished  with  a  card  showing  the 
dental  work  needed  and  were  referred  to  their  family  dentist  or  to  a 
dentist  in  the  neighborhood  in  which  they  resided.  The  plant  dentist 
s 


66  INDUSTRIAL    MEDICINE    AND    SURGERY 

would  then  supervise  this  dental  work  and  by  every  possible  means  short 
of  compulsion  would  persuade  the  employees  to  continue  treatment 
until  permanent  relief  was  afforded.  Most  of  this  dental  work  was  per- 
formed at  night  but  when  it  was  necessary  for  the  employee  to  report 
to  his  dentist  in  the  daytime,  this  was  done  on  the  company's  time. 
Those  stating  that  they  could  not  afford  to  pay  for  proper  dental 
care  were  given  a  loan  of  money  by  the  company,  said  loan  being 
repaid  at  the  rate  of  25^  to  50«f  a  week. 

This  dental  service  has  become  very  popular  with  the  employees 
and  the  results  obtained,  especially  the  decreased  loss  of  time  from 
work  due  to  diseased  teeth,  has  more  than  paid  for  the  cost  of  the 
dental  department. 

In  the  six  months  of  1914,  391  employees  were  cared  for  by  the 
dental  department;  in  1915,  6081  employees;  and  in  1916,  8502  em- 
ployees received  this  service.  These  figures  clearly  demonstrate 
the  need  for  a  dental  department;  that  such  service  is  looked  upon 
with  increasing  favor  by  the  working  force  is  evident. 

This  is  only  another  method  whereby  the  employer  can  express  a 
friendly  interest  in  his  employees.  The  returns  from  such  service 
are  shown  by  decreased  time  loss  from  work,  a  more  efficient  working 
force,  and  better  health  and  generally  increased  morale  on  the  part  of 
the  employees. 


CHAPTER  VI 

A    PRACTICAL    SYSTEM    OF   INDUSTRIAL   MEDICINE   AND 

SURGERY 

A  DETAILED  OUTLINE  OF  THIS  WORK  IN  ONE  LARGE  INDUSTRY 

In  the  metropolis  of  the  middle  west  industrial  medicine  and  sur- 
gery, as  it  is  known  in  its  broadest  aspects,  has  become  a  recognized 
specialty.  Here,  in  Chicago,  at  least  forty  of  the  larger  concerns  have 
developed  some  system  of  this  work  far  superior  to  the  old-time  plan 
of  a  company  surgeon  simply  to  bandage  the  injured. 

Co-operation  between  the  employers,  employees  and  the  various 
medical  staffs  has  resulted  in  the  rapid  growth  of  this  new  specialty, 
and  to-day  the  doctrine  of  human  conservation  is  fairly  established  in 
this  city.  The  practical  application  of  this  doctrine  is  yet  far  from 
completion. 

Here  you  see  the  Manufacturers  Association  holding  joint  meet- 
ings with  the  Industrial  Surgeons  Association,  the  Labor  Organi- 
zations doing  likewise,  and  all  of  these  being  represented  on  the 
Committee  on  Factories  of  the  Chicago  Tuberculosis  Institute,  the 
purpose  of  which  is  to  extend  this  work  into  all  industries.  Six  of 
the  largest  concerns  have  built  shacks  at  Naperville  for  the  free  care 
of  their  tuberculous  employees.  Thirty-eight  concerns  have  jointly 
bought  a  thousand  acres  of  land  in  New  Mexico  and  established  the 
Valmora  Sanatorium  for  the  care  of  their  more  advanced  tuberculous 
employees. 

But  other  cities  and  states  are  rapidly  overtaking  Chicago  in  this 
great  work.  Pennsylvania  Ohio,  Massachusetts,  Wisconsin,  Cali- 
fornia, and  a  few  other  states,  through  their  departments  of  Labor 
and  Industry,  have  given  a  wonderful  impetus  to  this  work,  and  no 
longer  can  any  one  locality  claim  to  be  a  leader  without  having  the 
point  well  and  vigorously  disputed. 

One  of  these  industries  in  Chicago,  employing  over  15,000  men 
and  women,  has  developed  a  system  of  industrial  medicine  and  sur- 
gery which  embodies  most  of  the  good  points  of  the  various  plans. 
Therefore  a  rather  detailed  outline  of  the  medical  work  in  this  indus- 
try is  herewith  submitted. 

The  doctor's  office  has  nineteen  rooms  finished  in  the  most  up-to- 
date  manner,  and  located  on  the  top  floor  of  the  main  building  away 
from  all  noise  and  dirt.  Every  ,room,  except  three,  has  outside  win- 
dow light.     These  rooms  are  for  the  following  purposes:  one  large 

67 


68 


INDUSTRIAL   MEDICINE    AND    SURGERY 


general  waiting  room;  one  large  office  and  record  room;  one  private 
office  for  the  chief  of  staff;  one  private  office  for  the  super  ntendent 
of  nurses  two  history  rooms;  four  examination  rooms  (one  equipped 
for  nose  and  throat  examinations) ;  a  laboratory;  a  drug  room;  two  well 
equipped  surgical  dressing  rooms;  a  sterilizing  room;  two  rest  rooms; 
and  two  toilet  and  bath  rooms. 

The  medical  staff  consists  of  nine  physicians,  two  dentists,  and 
twelve  nurses  during  the  busy  seasons,  and  drops  down  to  seven  doc- 


FiG.   14. — A  view  from  the  Doctor's  Office.     (Sears,  Roebuck  &  Co.) 

tors  during  the  summer.  An  oculist  is  on  the  staff  but  does  not  spend 
any  time  at  the  plant.  Each  doctor  spends  three  and  one-half  hours 
at  the  plant,  so  rotating  that  during  the  busy  morning  hours  there  are 
at  least  four  physicians  in  attendance,  the  remainder  filling  in  the  rest 
of  the  day. 

Recently  a  full-time  woman  physician  has  been  added  to  the  staff. 
Her  work  among  the  girl  employees  has  more  than  demonstrated  the 
great  advantage  of  having  a  diplomatic,  well-balanced  woman  physi- 
cian to  handle  many  of  the  problems  presented  by  the  girls. 


A  PRACTICAL  SYSTEM  OF  INDUSTRIAL  MEDICINE  AND  SURGERY    69 

Practically  every  one  of  these  doctors  is  a  specialist  in  some  line 
of  medicine  or  surgery,  and  his  work  at  the  plant  is  largely  along  this 
special  line.  Thus  two  good  surgeons  are  represented;  an  orthopedic 
specialist  is  of  the  greatest  value  in  many  of  these  cases;  a  specialist  on 
skin  and  venereal  diseases  is  in  constant  demand  for  diagnosis,  es- 
pecially in  differentiating  between  certain  skin  lesions  and  the  actue 
contagious  eruptions;  a  specialist  on  nervous  and  mental  d'seases, 
who  is  also  a  good  diagnostician,  conducts  many  of  the  examinations 
of  applicants  for  work.  Such  a  specialist  is  of  the  greatest  value  in 
fitting  handicapped  individuals  to  the  proper  job.  A  tuberculosis 
expert,  an  internist  and  a  gynecologist  are  also  included  on  the  staff. 
These  men  are  well-trained,  broad-gauged  industrial  physicians  during 
their  three  and  one-half  hours  at  the  plant,  capable  of  doing  any  work 
that  usually  falls  to  the  plant  physician.  The  remainder  of  the  day 
they  have  free  to  themselves  to  develop  their  special  line  of  work, 
and  incidentally  they  are  becoming  more  valuable  to  the  concern 
because  of  this  development. 

The  salaries  paid  these  men  are  good,  but  the  concern  could  not 
employ  them  for  full  time  without  an  outlay  that  would  make  it  pro- 
hibitive. But  two  good  men,  experts  in  their  line  of  work  and  of  con- 
siderable reputation  in  their  community,  can  be  employed  for  part 
time  and  their  combined  salaries  do  not  exceed  what  the  concern 
would  pay  for  one  mediocre  physician  giving  his  full  time  to  the  work. 

The  chief  surgeon  of  this  industry  likewise  devotes  three  and  a 
half  hours  of  his  time  at  the  plant.  In  the  afternoon  he  operates  on 
the  major  cases  sent  to  the  hospital  and  visits  all  such  cases  already 
in  the  hospital.  When  necessary  he  visits  the  employees  in  their 
homes.  The  administration  of  this  work  takes  most  of  his  time  while 
at  the  plant. 

None  of  the  medical  staff  is  allowed  to  accept  as  private  patients 
any  of  the  employees  of  this  concern.  This  is  necessary  to  remove  the 
idea  of  any  selfish  motive  on  the  part  of  the  doctor  when  he  strongly 
urges  them  to  undergo  some  remedial  work.  An  exception  to  this 
rule  is  when  some  one  of  the  managerial  force  desires  such  service 
from  one  of  the  staff  during  the  period  he  is  away  from  the  plant. 

The  duties  of  this  medical  staff  can  be  outlined  as  follows : 

1.  Emergency  treatment  for  all  injured  employees. 

2.  Subsequent  daily  dressings  of  injured. 

3.  The  care  of  major  surgical  cases  in  the  outside  hospital. 

4.  Free  surgical  care  for  those  who  cannot  afford  to  pay  for  proper 
care,  or  for  minor  conditions  which  would  be  neglected  if  the  employee 
was  referred  to  his  family  physician. 

5.  Free  surgical  care  for  all  cases  where  the  responsibility  for  their 
cause  is  doubtful. 


70  INDUSTRIAL   MEDICINE    AND    SURGERY 

6.  Free  surgical  care  for  members  of  the  employee'  family  where 
the  nurse's  report,  or  findings  of  the  welfare  department,  show  a  dire 
need  for  aid. 

7.  The  medical  examination  of  every  applicant  for  work  and  co- 
operation with  the  employment  department  to  place  the  handicapped 
in  suitable  occupations. 

8.  The  examination  of  old  employees: 

(a)  Those  returning  to  work  after  an  absence  on  account  of  illness. 

(b)  Those  seeking  a  pass  home  on  account  of  illness. 

(c)  Those  slated  for  re-examinations  because  of  some  pre-exist- 
ing condition. 

(d)  Those  seeking  medical  advice  because  they  have  learned  to 
use  the  doctor's  office,  or  on  the  suggestion  of  their  floor 
manager  (usually  because  they  "look  bad,"  are  "slowing-up" 
in  their  work,  poor  attendance,  etc.). 

(e)  Those  referred  from  the  surgical  department  for  examinations. 
(/)  Those  examined  for  membership  in  the  benefit  association. 
(g)  Those    working    in    hazardous    occupations.     Monthly    re- 
examinations are  made  of  all  exposed  to  occupational  diseases. 

9.  Supervision  of  those  needing  medical  treatment  until  they  are 
placed  under  the  care  of  the  family  physician  or  in  outside  hospitals. 

10.  Medical  treatment  where  investigation  shows  they  are  not 
receiving  proper  care. 

11.  Medical  treatment  furnished  free  for  all  tuberculous  employees, 
syphilitic  and  gonorrheal  cases,  and  for  those  needing  expensive, 
special  medical  care  but  who  cannot  afford  to  pay  for  it. 

12.  Emergency  medical  care  for  the  acutely  sick  or  for  those  with 
some  temporary  condition  which  medical  treatment  will  relieve  at 
once  and  allow  them  to  return  to  work. 

Every  case  must  be  handled  as  an  individual  and  no  hard  and  fast 
rules  can  be  laid  down  which  will  cover  every  condition  arising  during 
the  day's  work. 

13.  Periodical  sanitary  inspections  of  the  plant. 

14.  Supervision  of  the  ventilation,  lighting,  control  of  dust,  care 
of  cuspidors  and  toilets,  and  all  other  conditions  tending  to  promote 
health. 

15.  Co-operation  with  the  safety  engineer  in  the  prevention  of 
accidents. 

16.  Health  and  accident  prevention  talks  and  letters. 

17.  Fumigation  of  departments  where  contagious  cases  have  devel- 
oped, and  constant  watchfulness  for  new  contagious  cases. 

18.  Co-operation  with  the  visiting  nurses  to  relieve  conditions  found 
in  the  homes. 

19.  Co-operation  with  the  city  health  authorities,  the  Tuberculosis 


A  PRACTICAL  SYSTEM  OF  INDUSTRIAL  MEDICINE  AND  SURGERY     71 

Institute,  and  with  all  family  physicians  for  the  protection  of  the 
patient  and  the  community. 

20.  Co-operation  with  the  welfare  department  to  see  that  condi- 
tions revealed  by  the  medical  work  are  corrected  in  each  individual 
case,  as,  faulty  home  conditions,  lack  of  proper  food  and  clothing, 
insufficient  wage,  lack  of  recreation,  misfits  in  jobs,  trouble  between 
a  boss  and  an  employee,  and  numerous  other  conditions  tending  to 
undermine  the  health  of  the  workers. 

The  two  dentists  each  spend  four  hours  at  the  plant.  Their  duties 
are: 

1.  The  examination  of  all  applicants  found  with  bad  teeth  and 
referred  to  them  by  the  medical  staff. 

2.  The  examination  of  the  teeth  of  all  old  employees. 

3.  Recommending  necessary  work  to  be  done,  and  charting  this 
on  a  card  which  the  employee  is  told  to  take  to  his  family  dentist. 

4.  Co-operation  with  the  family  dentist  to  see  that  work  is  com- 
pleted and  reasonable  charge  for  the  same  is  made  and  paid  for. 

5.  Co-operation  with  the  welfare  department  to  arrange  loans 
when  necessary  so  that  the  family  dentist  can  be  properly  paid  at 
once.  The  employee  repays  the  firm  in  weekly  installments  of  fifty 
cents  each. 

6.  Periodical  re-examinations  to  see  that  work  recommended  for 
teeth  has  been  done  or  is  in  progress,  as  well  as  to  see  that  all  pro- 
phylactic care  is  being  carried  out  as  directed. 

7.  Consultation  work  with  the  medical  staff  in  running  down 
hidden  foci  of  in  ections. 

The  oculist  on  the  staff  receives  cases  sent  to  him  from  the  plant. 
The  ordinary  Snellen  test  is  made  at  the  plant  dispensary  and  those 
falling  below  a  certain  standard  are  referred  to  the  oculist.  The  latter 
examines  these  cases  and  corrects  all  with  faulty  vision.  A  loan 
arrangement  is  made  with  the  employee  whereby  he  can  pay  the 
oculist  a  reasonable  charge  and  then  repay  the  firm  as  described 
under  dental  cases.  The  details  of  this  work  are  described  in 
Chapter  XXV. 

The  nurses  devote  all  their  time  to  the  work.  Their  duties  are 
indicated  in  the  following  outline: 

1.  AU  twelve  nurses  spend  their  mornings  at  the  plant.  In  the 
afternoon  eight  of  them  visit  sick  employees  residing  in  their  prescribed 
districts. 

2.  Two  assist  the  surgeons  in  the  surgical  dressings.  They  also 
prepare  and  sterilize  all  dressings. 

3.  Four  are  engaged  in  history  taking  and  the  eye  tests.  This  is 
done  on  every  case  before  being  referred  to  the  doctors. 

4.  Two  are  present  in  the  girls'  examining  rooms  at  all  times. 


72  INDUSTRIAL    MEDICINE    AND    SURGERY 

5.  One  nurse  is  in  charge  of  the  drug  room,  issuing  medicine  only 
on  the  order  of  the  doctors. 

6.  One  is  in  charge  of  the  rest  rooms.  It  is  her  duty  to  see  that 
every  employee  going  to  the  rest  rooms  receives  every  attention  pos- 
sible, does  not  take  advantage  of  this  as  a  means  of  loafing,  and  that 
any  case  needing  medical  care  is  brought  to  the  attention  of  the  doctor. 

7.  The  superintendent  of  nurses  and  her  assistant  are  busy  in  the 
administration  of  this  machinery.  It  is  their  duty  to  see  that  every 
employee  is  waited  on  immediately  without  undue  loss  of  time  from 
his  work. 

The  visiting  nurses'  work  in  the  afternoon: 

1.  It  is  the  duty  of  each  nurse  to  visit  as  many  of  the  sick  em- 
ployees in  her  distr  ct  as  possible  during  the  afternoon.  In  order  to 
do  this  all  calls  are  restricted  to  those  employees  who  have  been  absent 
at  least  three  days,  and  only  periodical  calls  are  made  on  those  absent 
with  long  illnesses. 

2.  The  nurse  ascertains  the  condition  of  the  patient,  the  nature 
of  illness,  if  adequate  medical  or  surgical  care  is  being  given,  the  name 
of  the  family  physician,  the  home  conditions,  and  if  any  special  care 
is  needed  to  insure  the  patient's  recovery.  Whenever  necessary  the 
nurse  renders  nursing  care,  such  as  a  sponge  bath,  changing  of  the 
bed,  instructing  the  mother  or  wife  in  food  preparation,  etc. 

3.  The  nurse  reports  on  these  facts  at  once  by  telephone  if  urgent 
or  the  next  morning  on  her  return  to  the  plant. 

4.  By  co-operation  with  the  welfare  department  special  nursing 
care  is  given  to  a  sick  employee  when  these  reports  show  the  need. 
Or,  based  on  the  findings  of  the  nurse,  the  patient  may  be  removed  to 
a  hospital  and  further  treatment  rendered  by  the  medical  staff  of  the 
plant.  Food,  ice,  bed-clothing,  and  many  other  necessities  of  the 
sick-room  are  supplied  when  ready  money  for  these  is  lacking. 

5.  Reports  on  faulty  housing  conditions  are  investigated,  and  by 
diplomacy,  education,  and  the  judicious  use  of  money,  often  in  the 
form  of  increased  wages,  the  family  is  moved  into  healthier,  more 
sanitary  surroundings. 

An  expert  laboratory  girl  is  in  charge  of  a  well-equipped  labora- 
tory (Fig.  15).     Her  duties  can  thus  be  classified: 

1.  Urinalyses.^ — ^Every  applicant  for  work  and  every  old  employee 
given  a  thorough  medical  examination  likewise  has  a  specimen  of 
urine  examined.  Re-examinations,  two  or  more  times,  of  the  urine 
are  made  whenever  a  pathological  condition  is  found  in  order  to  be 
positive  of  that  condition  before  a  report  of  the  same  is  made  to 
the  employee. 

Five  years  ago  the  specimen  from  one  of  the  managers  was  ex- 
amined and  found  to  contain  sugar  in  large  quantity.     He  was  told 


A  PRACTICAL  SYSTEM  OF  INDUSTRIAL  MEDICINE  AND  SURGERY     73 

that  he  had  diabetes.  The  next  day  he  went  to  his  family  physician 
who  failed  to  find  anything  wrong.  After  seeing  three  good  inter- 
nists, all  of  whom  reported  the  urine  negative,  he  presented  himself 
before  the  chief  surgeon.  The  examination  at  this  time  was  also  nega- 
tive. This  man's  indignation  over  the  scare  and  expense  he  had 
been  subjected  to  was  a  source  of  great  embarrassment  to  the  doctor's 
office.  It  takes  months  to  live  down  one  little  mistake  like  this, 
which  all  doctors  know  is  liable  to  occur,  and  therefore  every  precau- 
tion is  taken  to  avoid  them. 


Fig.   15. — ^Laboratory  in  connection  with  Doctor's  OflBce. 

Specimens  of  urine  for  examination  are  secured  from  the  men 
directly  in  the  examining  rooms  where  special  arrangements  have  been 
made  for  this  purpose.  The  women's  specimens  are  obtained  in  the 
toilet  room  before  going  to  the  examining  rooms.  A  boy  and  a  girl 
respectively  carry  these  specimens,  properly  marked,  in  a  covered 
wire  compartment  basket  to  the  laboratory. 

2.  Blood  Analyses. — Every  employee  examined  whose  condition 
indicates  the  need  of  it  is  given  a  thorough  blood  examination  in  the 
laboratory  on  the  order  of  the  doctor.  This  includes  red  and  white 
count,  hemoglobin,  differential  count,  and  very  frequently  a  "Wasser- 
mann  test. 

3.  Sputum  Examination.^ — ^The  sputum  of  suspected  tuberculous 
employees  is  submitted  to  repeated  examinations.  Frequently  in 
cases,  clinically  tuberculous,  as  many  as  ten  to  twenty  sputum  ex- 
aminations are  made  before  the  bacilli  are  found.  It  is  only  by  using 
the  laboratory  to  its  uttermost  in  this  way  that  its  full  value  is 
obtained. 

4.  Bacteriological  Examinations. — Frequent  use  of  the  laboratory 
for  ascertaining  the  nature  of  infections  in  the  surgical  cases  is  resorted 


74  INDUSTEIAL   MEDICINE    AND    SURGERY 

to.  But  the  greatest  service  has  been  rendered  in  the  early  differential 
diagnosis  between  severe  tonsillitis  and  diphtheria.  Every  case  with 
the  least  suspicious  sore  throat  is  subjected  to  a  bacteriological  exami- 
nation. Smears  are  examined  at  once  and  cultures  prepared  and 
incubated  both  at  the  plant  and  at  the  city  health  department.  An 
average  of  one  out  of  twenty  of  these  cultures  is  positive  for  diphtheria 
but  in  its  discovery  the  fellow  employees  are  protected  from  this 
contagion.  Many  of  these  cases  of  diphtheria  are  very  mild  for  the 
individual  but  could  be  the  source  of  a  very  severe  epidemic  among  the 
others. 

5.  Stomach  Analyses  and  fecal  examinations  are  occasionally 
made  but  usually  the  employees  are  referred  to  an  outside  laboratory 
for  this  work. 

In  every  instance  the  family  physician  is  given  a  copy  of  the  labora- 
tory findings  in  order  to  aid  him  in  diagnosing  and  treating  the  case. 
The  average  family  physician  has  not  the  facilities  for  making  these 
laboratory  tests  early  in  the  course  of  the  disease,  and  they  are  there- 
fore not  usually  made  until  the  case  becomes  serious  or  evidence  of 
a  spread  of  contagion  indicates  their  need.  We  are  positive  therefore 
that  this  laboratory  has  been  the  means  of  saving  life  many  times. 
It  is  impossible  to  estimate  the  amount  of  lost  time  from  work  which 
it  has  saved. 

Example.^ — ^Lulu  M.,  an  employee  of  this  concern,  became  sick 
one  night  at  home.  The  third  day  of  her  illness  the  nurse  called.  She 
found  Lulu  suffering  from  stomach  trouble  or  ptomain  poisoning,  "the 
result  of  eating  fish."  The  family  doctor  had  been  in  to  see  her  every 
day.  The  nurse  reported  that  Lulu  seemed  very  sick  and  her  pain  was 
all  localized  in  her  right  side.  She  was  sent  back  the  next  day  and 
found  Lulu's  temperature  much  higher,  the  pain  more  severe  and  the 
abdomen  distended.  The  family  doctor  was  called  but  again  stated 
that  it  was  ptomain  poisoning  and  that  she  would  be  all  right  in  a  few 
days.  The  chief  surgeon  of  the  plant  was  informed  and  he  ordered 
the  laboratory  attendant  to  call  and  make  a  blood-count.  This  count 
showed  26,000  leukocytes.  Consultation  with  the  family  physician 
was  immediately  demanded,  and  as  a  result  he  was  convinced  of  the 
diagnosis  of  appendicitis  with  general  peritonitis  developing.  The 
girl  was  referred  to  another  surgeon  and  operated  at  once.  The 
abdomen  was  filled  with  pus.  The  appendix  was  never  found.  Ex- 
tensive drainage  saved  her  life,  but  five  months  elapsed  before  she  was 
able  to  return  to  work.  Her  position  was  one  in  which  an  experienced 
girl  meant  everything  to  the  work. 

Example. — Nellie  0.,  another  employee,  took  sick  while  at  work. 
She  was  sent  to  the  doctor's  office  but  wanted  to  go  right  home  as  she 
was  positive  her  abdominal  cramps  were  due  either  to  her  approaching 


A  PRACTICAL  SYSTEM  OF  INDUSTRIAL  MEDICINE  AND  SURGERY    75 

period  or  to  fish  she  had  eaten  at  lunch.  The  nurse,  however,  per- 
suaded her  to  be  examined.  The  doctor  found  tenderness  and  rigidity- 
over  the  appendix  region.  A  blood-count  was  made  and  showed 
18,000  leukocytes.  The  young  lady's  family  physician  was  called  and 
acquainted  with  the  facts.  As  Nellie  had  been  told  of  the  diagnosis 
and  the  importance  of  receiving  immediate  attention,  her  doctor 
suggested  that  she  be  sent  to  the  hospital  where  he  was  accustomed  to 
work.  This  was  done  (a  taxicab  being  used  for  the  purpose),  and  a 
nurse  went  to  the  girl's  home  and  notified  her  mother.  Four  hours 
later  Nellie  was  operated  and  a  gangrenous  appendix  removed.  She 
was  back  at  work  in  three  weeks.  Nellie's  home  conditions  were 
known,  and  the  careless  attitude  of  her  family  toward  disease,  and  there 
is  no  question  but  what  weeks  of  illness,  if  not  her  life,  were  saved  by 
this  prompt  action. 

During  1916  there  were  200  cases  of  appendicitis  diagnosed  in  this 
way.  Some  of  these,  who  had  no  family  physician,  or  were  boarding 
in  the  city,  or  for  other  reasons  could  not  receive  proper  attention  at 
home,  were  operated  at  once  by  the  chief  surgeon.  The  others  were 
referred  to  their  family  physicians  but  were  so  closely  followed  up  by 
the  medical  staff  that  proper  surgical  care  was  soon  given  in  every 
case.  None  of  these  died.  During  this  same  period  two  deaths  from 
appendicitis  occurred  among  employees  who  had  become  sick  while 
at  home  and  therefore  did  not  have  the  advantages  of  this  scientific, 
diagnostic  attention. 

Example. — In  one  department  tonsillitis  became  quite  prevalent. 
The  first  four  cases,  however,  developed  the  disease  at  home.  The 
fifth  came  to  the  doctor's  office.  Smears  were  taken  from  the  throat 
but  showed  nothing  suspicious.  However,  cultures  were  made. 
The  next  morning  a  diagnosis  was  made  of  diphtheria.  The  family 
physician  was  notified  and  he  gave  antitoxin  treatment  at  once. 
A  nurse  immediately  called  on  the  other  girls  and  made  smears  and 
cultures.  Three  of  these  had  diphtheria.  The  department  was 
fumigated  and  every  throat  examined  bacteriologically.  Only  one 
other  case  of  diphtheria  developed,  although  the  people  in  that  depart- 
ment were  watched  very  closely.  It  is  easily  conceived  that  this 
prompt  action  aborted  a  more  than  incipient  epidemic. 

An  industrial  medical  and  surgical  service  such  as  described  needs 
a  considerable  clerical  force  to  carry  on  this  work.  In  addition  to 
the  medical  and  nursing  staff  this  office  employs  one  office  manager, 
a  private  secretary  to  the  chief  of  staff,  four  record  clerks  for  the  med- 
ical cases,  one  record  clerk  for  the  surgical  cases,  a  girl  who  stamps 
the  coming  and  going  of  each  patient  with  a  time  clock  (this  is  neces- 
sary where  500  and  more  employees  visit  the  doctor's  office  during  the 
day,  to  prevent  undue  loss  of  time  from  a  patient  being  overlooked), 


76  INDUSTRIAL   MEDICINE    AND    SURGERY 

and  a  girl  in  charge  of  telephones.  Two  colored  matrons  are  in  con- 
stant attendance  to  keep  the  offices  clean. 

"While  this  chapter  is  dealing  with  the  specific  medical  and  surgical 
work  of  an  industrial  plant,  yet  it  is  impossible  to  draw  a  line  between 
this  work  and  that  of  the  so-called  welfare  department  in  many  in- 
stances. The  two  must  work  in  the  closest  co-operation.  For  that 
matter  the  profession  is  recognizing  more  and  more  the  indispensable 
aid  which  social  workers  and  all  social  movements  are  giving  to  medical 
treatment. 

Medicine,  the  exalted,  has  descended  to  a  human  plane,  and  in  the 
industrial  world  and  in  many  other  places  we  are  witnessing  a  marriage 
between  medicine  and  sociology. 

In  this  concern  the  welfare  department  (which  by  the  way  is  not 
known  by  that  terminology)  co-ordinates  the  work  between  the  safety 
engineer  and  the  medical  staff,  and  authorizes  the  changes  in  plant 
sanitation  recommended  by  the  medical  staff.  All  suggestions  along 
the  lines  of  industrial  hygiene  and  individual  hygiene  are  put  into  opera- 
tion or  assisted  by  this  department.  It  provides  restaurant  service 
for  the  employees  and  supervises  the  food  preparation.  It  provides 
recreation  rooms  for  the  girls  and  various  kinds  of  entertainments. 
For  the  men  athletic  fields,  tennis  courts,  ball  diamonds,  and  all  types 
of  healthful  recreation  are  under  this  department's  supervision. 

Investigations  of  housing  conditions  and  co-operation  with  the  city 
authorities  and  with  other  industries  for  the  correction  of  faulty  con- 
ditions come  within  the  scope  of  this  department  and  here  it  has  a 
very  definite  connection  with  the  medical  and  surgical  work. 

Transportation  problems,  overcrowded  street  cars,  ill-ventilated 
and  cold  cars;  collection  of  garbage,  cleaning  of  streets  and  alleys, 
sewage  conditions,  and  all  public  health  problems  must  be  entered 
into  by  the  welfare  department,  assisted  by  the  medical  staff,  as  a 
means  of  maintaining  the  health  standards  fixed  by  this  industry. 

No  system  of  industrial  medicine  can  be  perfected  that  does  not 
take  cognizance  of  the  conditions  in  the  community  from  whence  its 
employees  come. 

To  the  uninitiated,  or  to  the  average  employer  thinking  only  of 
production,  the  large,  expensive  medical  and  welfare  departments 
herein  outlined  seem  a  rather  extravagant,  non-producing  piece  of 
machinery.  No  effort  will  be  made  to  refute  this  impression,  leaving 
that  argument  for  a  subsequent  chapter. 

This  establishment  has  endeavored  to  build  up  a  comprehensive 
system  for  conserving  its  human  machinery.  Even  the  size  of  its  staff 
is  not  sufficient  to  do  all  that  should  be  done.  For  instance,  much 
better  results  would  be  obtained  if  competent  medical  and  surgical  care 
were  furnished  at  a  reasonable  price  to  every  employee.     The  nursing 


A  PRACTICAL  SYSTEM  OF  INDUSTRIAL  MEDICINE  AND  SURGERY    77 

staff  should  be  enlarged  so  that  a  visit  could  be  made  on  every  employee 
the  first  day  of  his  illness  and  as  often  thereafter  as  was  indicated.  A 
nearby  hospital  for  the  immediate  care  of  serious  cases  would  be  much 
better  than  transporting  them  two  or  three  miles  to  a  general  hospital. 
Many  other  improvements  will  suggest  themselves  to  the  industrial 
surgeon. 

The  following  table  from  the  hospital  report  of  this  concern  dem- 
onstrates the  need  of  the  present  size  of  its  medical  staff : 


Table  1 
SUMMARY  REPORT  OF  WORK  OF  MEDICAL  STAFF 


Years 

1914 

1915 

1916 

1917 

Total  number  examinations 

12,380 

23,771 

28,167 

391 

5,470 

16,535 

28,009 

25,944 

6,081 

4,702 

24,826 

37,906 

35,216 

8,502 

6,374 

30,100 

37,900 

33,481 

3,746 

6,561 

Total — Medical    cases 

Total — Surgical   cases 

Total  — Dental  cases 

Total — Nurses    visits ' 

Grand   total 

70,179 

81,271 

112,824 

111,7881 

1  Decrease  in  amount  of  work  due  to  reduced  staff  because  of  war  service. 


78 


INDUSTRIAL   MEDICINE    AND    SUEGERY 


.«->*' 


;^vx\^\\\\vv<==4K\\\s==^=iv\'^^ 


S  T/^ooa  >iava 


i^'K^VV\\V\V\V\VV\^^\VV^\H^^l\\\\^l==l^^         \-^^-']         [,\\\\\V\\V\\\'t^ 


CHAPTER  VII 

BENEFITS  AND  PROFITS  OF  THE  MEDICAL 
DEPARTMENT 

The  ramifications  and  influences  of  a  genuine  human  maintenance 
department  in  any  industry  are  so  intricate  and  subtle  that  it  is  im- 
possible to  estimate  in  dollars  and  cents  the  tangible  returns  from  such 
a  system.  The  salaries  of  the  doctors  and  nurses,  the  rental  of  the 
office  space,  the  supplies  used,  the  equipment,  the  outside  hospital  bills, 
and  all  other  expenditures  can  be  ascertained  to  an  exactness  and 
represent  the  cost  to  the  employer  of  such  a  department. 

But  when  the  employer  endeavors  to  definitely  determine  or  approxi- 
mately estimate  the  actual  monetary  returns  from  this  investment  he 
is  soon  hopelessly  confused. 

How  can  he  estimate  the  financial  returns  due  to  the  increased 
efficiency  of  an  employee  who  for  years  has  been  below  par  because  of 
some  chronic  ailment  which  was  discovered  and  removed  by  the  med- 
ical department,  thereby  restoring  this  man  to  full  producing  capacity? 
During  each  succeeding  year  the  number  of  these  restored  individuals 
throughout  the  working  force  is  increased  making  his  problem  even 
harder. 

How  can  he  estimate  the  returns  from  the  cure  of  hundreds  of 
employees  suffering  from  imaginary  diseases?  These  men  and  women 
imagining  that  they  have  heart  disease,  kidney  trouble,  "displaced" 
vertebrae,  lung  trouble,  "ulcers,"  and  numerous  other  conditions, 
ease-up  on  their  work  to  protect  their  health.  They  move  slowly, 
appear  distraught,  and  worry  incessantly  over  their  condition.  Some 
take  time  from  work  to  go  from  doctor  to  doctor,  while  others  shun 
a  physician  dreading  to  have  their  fears  confirmed.  These  neuras- 
thenics make  up  a  large  proportion  of  the  medical  work  of  an  industrial 
dispensary.  Their  efficiency  is  greatly  reduced  but  to  what  extent 
it  is  impossible  to  say.  The  industrial  surgeon  examines  and  re- 
examines them,  gains  their  confidence,  and  finally  convinces  them 
that  no  organic  disease  is  present.  This  may  be  accompHshed  at  once 
or  it  may  take  weeks  of  patient  psychotherapy.  But  the  buoyant 
spirits  which  replace  the  depression,  the  added  "pep,"  the  increased 
efficiency  resulting,  bring  great  returns  to  the  employer — returns  of 
which  he  is  seldom  aware,  and  cannot  compute. 

When  a  foreman  is  the  victim  of  this  neurasthenic  condition  he 

79 


80  INDUSTRIAL   MEDICINE    AND    SURGERY 

can  become  a  source  of  great  loss  to  the  employer.  His  worries  and 
depression  react  on  the  men  and  women  under  him.  It  is  a  contagious 
condition.  Many  of  his  employees  will  develop  imaginary  ailments. 
Or  the  worried  foreman  grows  irritable  and  is  unjust;  thus,  the  labor 
turn-over  in  that  department  increases  and  the  productivity  decreases. 
The  foreman  is  censured  by  the  management  and  this  adds  to  his  nerv- 
ous condition.  An  alert  industrial  surgeon  soon  learns  to  recognize 
such  a  situation  and  becomes  the  efficiency  expert  who  remedies  the 
trouble.     But  who  can  estimate  the  dollar  and  cent  value  of  such  work? 

What  sum  will  the  employer  place  in  his  debit  column  to  represent 
the  increased  productivity  resulting  from  the  happier,  more  contented, 
healthier  working  force,  the  direct  result  of  a  human  maintenance 
department  such  as  has  been  described  in  the  preceding  chapters? 
When  a  concern  adopts  such  a  system  it  is  usually  due  to  an  awakened 
conscience,  a  desire  to  improve  the  welfare  of  its  employees.  There- 
fore, many  other  betterment  movements  are  installed  besides  the  health 
department.  Thus  it  is  often  impossible  to  separate  the  returns  from 
the  medical  work  from  those  of  other  types  of  welfare  work.  In  a 
majority  of  industries,  however,  the  medical  department  lias  been  the 
forerunner  and  incentive  for  this  additional  work. 

Since  our  employer  is  unable  to  demonstrate  actual  financial  gains 
from  his  medical  department,  it  behooves  industrial  surgeons  to  show 
in  some  concrete  form  what  benefits  he  may  expect  from  such  a 
system.  Since  these  benefits  must  react  to  the  good  of  both  the 
employee  and  employer  before  either  can  receive  full  compensation, 
we  must  show  them  in  terms  of  both.     Table  2  endeavors  to  do  this. 

Whenever  an  elaborate  medical  system  is  installed,  both  the  em- 
ployer and  the  doctor  expect  to  see,  after  a  year  or  two,  a  reduction  in 
the  number  of  cases  needing  treatment.  Both  will  be  disappointed 
providing  the  medical  department  is  successful  and  gains  the  full  con- 
fidence of  the  employees.  A  medical  service  which  can  show  such 
a  reduction  is  failing  in  its  purposes. 

It  takes  at  least  a  year,  and  usually  five  years,  before  the  company 
doctors  gain  the  confidence  of  the  working  force.  As  this  confidence 
increases  the  number  of  cases  coming  to  the  office  for  advice  or  treat- 
ment will  increase.  This  is  desirable  for  the  greater  number  of  em- 
ployees visiting  the  doctor's  office  affords  a  correspondingly  greater 
supervision  over  their  health.  After  a  few  years  these  employees 
develop  the  habit  of  coming  to  the  doctor's  office  for  threatened  ail- 
ments instead  of  awaiting  the  full  development  of  some  diseased  con- 
dition. This  affords  the  opportunity  of  treating  sickness  in  its  earliest 
stage  and  aborting  more  serious  trouble.  The  few  minutes  necessary 
to  visit  the  doctor's  office  for  this  purpose  is  a  great  saving  of  time  when 


BENEFITS    AND    PROFITS    OF    THE    MEDICAL   DEPARTMENT      81 


T3 

a 
^ 


W 


w 


rt 


<1  IS 


M 


I— I   '^ 


9  -^ 


.2  § 
1  J 
9^  '3 


o3 


W     1=1 


b\2 


03 
O      01 


5       2 


Sea 

CO     oj     r- 
(i;      O      a; 

g    OJ    o 


:3l  11 


o3    cc 


5R    bC 


5^    S    «  ^ 
T3  -d  ^  -J 

Ph     OJ   Ph     o3  I— I  «« 


e3       . 

£    «^    "    -^ 

O     S     S     g 


g  ■«  03  O  03  CU 
0  0)00 
l-H    ^    HH    C/2 


<u 


„  a;  > 

o    o  X  o 

g    o  !^  .S2 

CO     CO  O  tJ 

•^      -f^S  t+-4 


a     o3 

03      O 
OJ      >J 

^  a 
•  S  ° 

w   Tl,    bC 
bJO    M    S^ 

S^    03  -S 

""   -S  'O 

t^  C  tH 


<D 


02     CD 


O 

03    '73 


'^i     o  <"     "  "-^ 

R  -^  bC   o  o 

'    '^  ^    a  M 

_     CO  ^     S  03 

g     S  'd     O  M 

2  T3   =«  ^ 


X3 


£  .2  <u 


o  tJ  C3 

o  "^  ^  =. 

CO  C  fl  o 

3  p  o  O 

O  >  -rt  -e 


S    ^ 


•?H         C 


.     o3 
•73     03 

£^ 


^       O) 


O)      Ol 

a>    03 


«        ^  ^  -C 


a; 


03 


C  ^        tH 


CO     2? 


o 


P^   32  t3  Ph 


01  ^     5 

.^   a  '^ 


03  3  "tJ 

4^  T3  -73 

vh      O)      03  OJ  rj 

£  CQ  PQ  rt  i 


t^    00    Oi 


tH   a 


O      O      03      03 

T-I  c<i  fo 


03 


ill 


e3 


a  t3 

d    (3 


^    o    o 


•s  a 


W  Q  pq 


e3 


02      03      >J 

t>s     (d      03 
O 


03 


2    .a      bJO   J 
03     03     Sx    -►^ 


03 

t-i      03 


.3      >l 


8    O 

•S  .2 


■2  S 

_r3    03 


CD  r!  -«  bio 

"2  rl  ^  f3 
o3  °  fe^  d 
03     03   <i   02 

03      s_, 

■-3  "^  S  S 

S    5h    2    ^  '-d  -:3  ^  '-T^  ■■+3 

§<.§.§  .S  -g   S   a  d   fl 

3r3do3a3gria3a> 
~oSS-5a3-^^<^<^<3^ 
JWH-<P-i    ftPHPnP^ 

^     .     .     .     .  ... 


>i    03    .T3 

c  03  .a 

e  J  fl  3  o  -^ 

o  S  o  .  -ff  ^  - 

•.e  .2  -^s  bc  g  03  ^ 

e  -g  03  c  03  >  .3 

•g  +i  -^  -tj    a,  ^  ^ 

§    'S      1=3    'S,     S      K      03      03' 

"g 

e   T-l   (N    CO   ■<**    "3    CO 


'82 


INDUSTRIAL   MEDICINE    AND    SURGERY 


r2      ^ 


^1 

o    c- 

0) 

•in      c3 

a 

03  p— 

m     o3 

H^ 

fi  .-S 

'o 

a& 

M 

IB 

o 

o    m 

m 

w    ^ 

IB 
O 

nd 

tS    o 

<B 

<D      0) 

tf  rt  Q 

1— 1 

(N    CO 

a 


ci       4       S   g   ^ 


?  ^ 


O 

> 

CD 

;h 

•li 

L^ 

fL,  P^  Pm 

T-H 

im' 

CO 

o     >> 


73 

t3 

.2 

XD 

"^H 

CD 

O 

73 

:3 

p: 

•n 

o 

CD 

OJ 

fl 

^ 

_o 

o 

'•+3 

o3 

ti 

O 

>. 

c3 

a 

o 

t4_4 

o 

C 

o 

_aj 

o 

73 

o 

'3 

<U 

5E 

0) 

bX] 
.3 

-rs 

Li 

o 

73 

a 

o 

o 

'^ 

:3 

>l 

•73 

c3 
> 

^ 

o 
o 

^ 

bC 

3 

a 

73 

«4-l 

CO 

73 

73 

S 

01 

o 

o 

D< 

1— H 

03 

'T3 

73  & 


^ 


V        9.       ^  ^   ^.  -S  -3    _.        q 


o 
o 

o3 


a 


bD 

i  s  ^ 


> 


oj 


(B    fl    a> 
PQ  M  Q 


'^         Q;9<TS^i»o.-  .oo3 

r^Br/lO  r-l  CD       ^       ^ 


raiS  O  ^_!'">^'T-!'-^  CD 


bC  . 


I       1-^  §D-^  "^  S-l^^:   ^^       -l-Sig-g 

03    O  ac  bCg  bJOMfl^     bJ3bX)0^     ^.S     03 

k -^ -S  ^  •  3  >  II  J  g^  >  I  g  ^  •  3  g  g 

"^s.  i-I  im'  CO  ■*'  id  .2  rH  (N  CO    s  r-I             (m'  co'  -*'  id 

OQ  1^  feq 


BENEFITS   AND    PROFITS    OF    THE    MEDICAL   DEPARTMENT      83 

compared  with  the  few  days  or  weeks  which  may  result  from  neglect- 
ing minor  symptoms. 

These  same  employees  would  not  seek  the  counsel  of  their  family 
physician,  because  of  the  expense,  for  these  apparently  trivial  matters, 
whereas  they  will  come  to  the  doctor's  office  providing  this  confidence  is 
established.  With  each  succeeding  year,  therefore,  the  number  of 
medical  cases  increases.  The  doctor  soon  learns  to  eliminate  those  who 
are  taking  advantage  of  the  system. 

The  medical  cases  not  only  increase  but  apparently  the  surgical 
cases  likewise  and  this  in  spite  of  the  fact  that  accident  prevention 
methods  are  always  installed  wherever  a  human  maintenance  depart- 
ment is  in  existence.  The  safety  first  measures  reduce  the  number  of 
serious  accidents,  but  the  minor  and  so-called  trivial  injuries  are  almost 
impossible  to  prevent.  But  we  can  prevent  infections  and  other  serious 
complications  from  developing  in  these  minor  accidents.  Experience 
has  taught  us  that  the  greatest  safety  first  measure  for  these  minor 
injuries  is  the  immediate  reporting  to  the  surgeon  for  proper  treat- 
ment. In  a  concern,  therefore,  where  the  medical  department  is 
efficient  each  year  will  show  an  increase  in  the  number  of  employees 
reporting  for  immediate  care  of  all  injuries  no  matter  how  trivial. 
In  which  case,  each  year  will  show  a  corresponding  decrease  in  the 
number  of  infections  resulting  from  injuries. 

In  an  industry  employing  an  average  of  12,000  men  and  women, 
which  adopted  an  efficient  medical  and  surgical  system  nine  years  ago, 
the  following  table  illustrates  the  increased  confidence  of  the  employees, 
the  better  medical  supervision,  and  the  greater  surgical  preventive 
measures  which  developed  with  each  succeeding  year: 

Table  3 

Year  Number  of  medical  and  surgical 

visits  to  doctor's  office 

1909 14,643 

1910 17,889 

1911 22,400 

1912 48,000 

1913 56,720 

1914 70,179 

1915 81,271 

1916 112,824 

The  question  naturally  arises,  did  not  this  great  increase  in  the 
number  of  patients  using  the  doctor's  office  make  the  cost  of  such  a 
system  prohibitive  ?  The  best  reply  to  this  question  is  to  submit  the 
following  comparative  report  of  the  cost  of  medical  and  surgical  work 
for  two  years  in  this  same  concern: 


84  INDUSTRIAL    MEDICINE    AND    SURGERY 

Table  4 
COST  OF  MEDICAL  AND  SURGICAL  SUPERVISION  OF  EMPLOYEES 


1915 

1916 

Increase, 
per  cent. 

11,068 

0 

6 

1 

12 

32,800 

15,447 

4,137 

52,384 

4,702 

174 

2,666 

16,535 

$38,239.59 

$3.46 

81,271 

13,324 

1 

7 

1 

12 

43,766 

22,486 

6,870 

73,122 

6,374 

262 

3,341 

24,826 

$49,075.99 

$3.68 

112,824 

20.4 

Plivc!if>ifin<5  pmnlnvpd  full  time        

16.7 

Physicians  engaged  for  call  service 

Surgical  and  medical  cases  treated 

33.4 
45.6 

66.1 

Total    medical    and     surgical    visits     to 

39.6 

35.6 

50.6 

25.3 

Physical  examinations  made       

50.1 

Total  medical  and  surgical  cost 

28.3 

Average  cost  per  employee         

6.4 

Total  nAjmber  of  patients  visiting  doctor's 
office                      

38.8 

You  will  note  that  the  per  cent,  of  increase  in  the  medical  staff  is 
below  the  per  cent,  of  increase  in  the  number  of  employees.  The  average 
amount  of  increase  in  the  medical  and  surgical  work  is  43.2  per  cent., 
while  the  increase  in  the  total  cost  is  28.3  per  cent.  But  the  actual 
cost  per  employee  for  the  year  1916  was  only  twenty-two  cents  more 
than  for  1915.  A  cost  of  only  $3.68  per  employee  per  year  for  such  an 
extensive  amount  of  work  is  certainly  not  prohibitive. 

However,  it  is  impossible  to  show  in  dollars  and  cents  what  the 
income  amounted  to  from  this  work.  We  can  only  prophesy  and 
estimate  what  the  loss  in  time  and  loss  in  compensation  might  have 
been  without  it.  Some  of  the  sources  of  profit  to  this  concern  from 
their  human  maintenance  department,  however,  can  be  classified  as 
follows : 

1.  An  average  of  500  applicants  for  work  per  year  or  3.4  per  cent, 
who  had  diseased  conditions  unfitting  them  for  employment  have 
been  weeded  out,  thus  reducing  labor  turn-over. 

2.  One  hundred  and  sixty-three  cases  of  active  tuberculosis  were 
prevented  from  being  employed  during  a  period  of  three  years,  thus 
protecting  the  old  employees,  preventing  loss  of  time  due  to  the  spread 
of  the  disease,  reducing  labor  turn-over,  and  eliminating  inefficient 
employees — a  group  who  would  have  had  a  gradual,  imperceptible 
slowing-up  in  their  work. 

3.  Discovering  263  cases  of  tuberculosis  among  the  old  employees 


BENEFITS    AND    PROFITS    OF    THE    MEDICAL   DEPARTMENT      85 

during  the  same  period,  the  majority  of  whom  were  found  in  the  in- 
cipient stage,  thus  accomplishing  the  same  results  set  forth  in  2. 

4.  During  the  so-called  "grip"  epidemic  of  the  winter  of  1915  and 
1916  the  medical  work  in  this  concern  held  the  number  of  absentees 
down  to  9  per  cent,  of  the  total  working  force  during  a  period  of  four 
months.  Whereas,  several  concerns  had  an  absentee  rate  from  25  to 
33)-^  per  cent,  of  their  total  number  of  employees  during  that  epidemic. 

5.  Labor  turn-over  has  been  reduced  to  a  considerable  extent  in 
this  industry,  but  as  many  other  factors  enter  into  this  the  medical 
work  can  only  be  given  credit  for  a  part  of  this  reduction. 

6.  The  number  of  infections  following  injuries  has  been  reduced 
from  28.6  per  cent,  in  1912  to  7.57  per  cent,  in  1916.  The  time  lost 
from  infections  in  1912  amounted  to  1987  days,  or  an  average  of  2^^ 
days  per  case,  while  time  loss  from  this  cause  in  1916  amounted  to 
816  days,  or  an  average  of  Ij-'g  days.  This  was  accomplished  in  spite 
of  the  fact  that  the  working  force  had  increased  approximately  one- 
fourth  during  the  same  period.  This  represents  a  saving  of  some 
$3000  in  wages  and  approximately  $5000  in  hospital  bills,  compensa- 
tion, etc. 

7.  Because  of  this  health  supervision  and  preventive  surgery 
a  few  deaths  are  prevented  every  year.  On  an  average  of  twice 
every  year  the  medical  supervision  has  prevented  this  concern  from 
being  blamed  with  a  death  for  which  they  were  in  nowise  responsible, 
thus  saving  either  compensation  for  loss  of  life  or  long  and  expensive 
litigation. 

Example. — The  visiting  nurse  reported  that  an  ex-employee  was 
in  a  hospital  dying.  His  doctor  had  diagnosed  lead  poisoning  and 
blamed  his  work  in  the  printing  department  for  the  condition.  Ref- 
erence to  his  records  showed  that  he  had  been  examined  in  the  doctor's 
office  several  times.  A  lowgrade  nephritis  had  been  diagnosed.  There 
was  also  a  history  of  syphilis  The  man  quit  his  job,  and  the  company 
surgeon  had  lost  track  of  his  case  for  several  months.  Consultation 
with  the  attending  physician  was  sought  and  granted.  The 
examination  of  the  patient  at  this  time  showed  a  saddle  anesthesia, 
a  three  plus  Wassermann  reaction  in  the  spinal  fluid,  and  other  symp- 
toms justifying  a  definite  diagnosis  of  cerebrospinal  syphilis.  Lead 
poisoning  was  ruled  out  to  the  satisfaction  of  his  family  physician. 
The  man  died  a  few  days  later.  His  wife  secured  a  lawyer,  but  the 
case  was  so  thoroughly  worked  up  that  it  was  dropped,  no  effort  being 
made  to  collect  an  unjust  claim. 

Similar  cases  are  very  common  in  the  experience  of  every  surgeon 
in  industry,  and  it  is  impossible  to  estimate  the  savings  to  their  con- 
cerns by  avoiding  compensation  and  litigation  due  to  these  unjust 
death  claims. 


86  INDUSTRIAL   MEDICINE    AND    SURGERY 

One  of  the  greatest  spurces  of  saving  to  the  employer  is  the  physical 
selection  of  employees  for  work.  This  is  done  by  the  physical  examina- 
tion of  all  applicants  for  work  before  employment.  The  value  to  the 
employer  depends  upon  the  thoroughness  of  these  examinations  and 
the  amount  of  co-operation  between  the  employment  department,  the 
medical  department  and  the  foreman. 

The  old  system  in  vogue  before  medical  examinations  of  employees 
was  introduced  into  industry,  and  which  is  still  in  vogue  in  so  many 
places,  resulted  in  the  following  wasteful  methods: 

1.  A  man  appUed  to  the  employment  department  or  to  the  foreman 
for  a  job.  He  had  had  words  with  his  foreman  in  another  industry 
and  quit.  (This  was  the  result  of  less  and  less  work  due  to  a  physical 
handicap  of  which  he  was  not  aware.)  Experience  made  him  valu- 
able for  certain  types  of  work.  He  was  employed  and  thrown  into 
the  human  machinery  of  that  industry  without  any  investigation  as 
to  his  physical  fitness.  His  work  was  on  a  machine  and  was  very 
heavy.  He  exerted  himself  to  make  good  and  at  first  succeeded,  but 
gradually  the  production  of  his  machine  fell  behind  and  after  two 
months  the  foreman  was  forced  to  let  this  man  go.  For  two  months 
an  expensive  machine  had  failed  to  produce  sufficiently  to  pay  for 
its  maintenance;  a  definite  loss  for  the  employer.  And  why?  Be- 
cause this  man  who  was  employed  blindly  had  a  beginning  locomotor 
ataxia  and  was  physically  unable  to  make  good.  An  examination 
when  he  applied  would  have  prevented  his  employment,  saved  the 
loss  from  inefficient  operation  of  the  machine,  and  the  cost  of  hiring 
and  firing  a  man. 

2.  A  man  was  employed  as  a  laborer  by  an  electrical  concern.  This 
concern  had  a  medical  staff  but  did  not  include  medical  examination 
of  applicants  as  a  part  of  their  work.  Therefore,  this  laborer,  without 
knowing  his  fitness,  was  assigned  to  help  repair  boilers.  After  two 
weeks  of  work  this  man  suddenly  dropped  dead.  At  the  time  of 
death  he  was  drawing  an  electric  light  attached  to  a  wooden  handle 
into  the  boiler  and  in  falling  this  light  was  broken  and  a  fuse  burned 
out. 

At  autopsy  it  was  found  that  this  man  had  an  old  chronic  heart 
lesion  and  death  was  due  to  acute  dilatation  of  the  heart.  There  was 
no  sign  of  an  electrical  burn.  But  the  coincidence  of  the  light  break- 
ing and  the  fuse  burning  out  was  seized  upon  by  his  relatives  and  a 
shyster  lawyer  and  made  the  basis  of  a  claim  before  the  Employees 
.Compensation  Board.  Thirty-five  hundred  dollars  was  allowed  by 
this  Board. 

The  concern  carried  the  case  to  court  and  after  a  long  fight  and  by 
employing  expert  witnesses  they  were  absolved  of  all  responsibility 
for  the  man's  death. 


BENEFITS  AND  PROFITS  OF  THE  MEDICAL  DEPARTMENT   87 

This  blindly  hiring  of  a  defective  human  machine  cost  this  concern 
over  $5000  for  two  weeks  of  service. 

The  placing  of  all  comers  on  jobs  without  any  effort  at  a  physical 
selection  for  their  work  is  responsible  for  a  great  financial  waste  which 
cannot  be  shown  in  dollars  and  cents  but  which  nevertheless  is  very 
evident. 

This  waste  is  due  to  the  following : 

1.  The  employment  of  the  physically  unfit  who  later  must  be 
discharged  because  of  inability  to  do  tHe  work. 

2.  The  employment  of  the  physically  unfit  who  continue  to  work 
for  a  few  months  or  a  year  with  a  gradual  decrease  in  their  efficiency 
due  to  the  advancing  disease  until  finally  they  are  forced  to  quit  work. 
They  have  been  a  source  of  loss  to  the  concern  from  the  time  of  their 
employment. 

3.  The  employment  of  the  physically  unfit  who  because  of  their 
condition  are  subject  to  frequent  accidents.  Every  accident  is  a  loss 
to  the  concern. 

4.  The  employment  of  the  physically  unfit  who  suffer  accidents 
which  ordinarily  would  not  be  serious  but  because  of  the  coincidental, 
unknown  physical  condition  are  fatal,  or,  at  least,  cause  prolonged 
disability.  The  loss  to  concerns  from  this  source  is  far  heavier  than 
any  employer  is  aware  of. 

5.  The  employment  of  the  person  with  some  contagious  disease 
who  communicates  it  to  others  in  the  working  force.  The  acute 
contagious  diseases  are  more  common,  but  tuberculosis  and  syphilis 
also  cause  a  great  loss. 

6.  The  employment  of  the  mentally  deficient  who  never  can  be 
fitted  to  a  job  and  who  form  a  certain  percentage  of  floating  labor  on 
account  of  this  fact.  An  observant  industrial  physician  will  pick  out 
this  type  during  the  course  of  his  examination. 

Those  concerns  which  have  an  efficient  medical  system  always  in- 
clude the  examination  of  applicants  as  a  definite  part  of  the  work. 
These  examinations  are  not  made  for  the  purpose  of  selecting  only  the 
physically  fit  and  refusing  employment  to  all  others,  but  are  made  for 
the  following  purposes: 

(a)  To  prevent  those  with  diseased  conditions,  making  work  of 
any  kind  dangerous  to  them,  from  going  to  work;  (6)  to  select  proper 
jobs  for  those  with  certain  defects  where  they  can  still  be  efficient 
and  yet  the  work  will  not  be  hazardous  to  them;  (c)  to  prevent 
those  with  contagious  diseases  from  mingling  with  the  old  working  force. 

The  author  has  collected  statistics  from  ten  large  industries,  having 
very  excellent  medical  staffs,  which  examine  all  applicants  for  work. 
Their  rejections  are  based,  for  the  most  part,  on  the  above  standards. 
The  following  table  shows  the  results  of  these  examinations : 


88  INDUSTRIAL   MEDICINE    AND    SURGERY 

Table  5 

1.  Total  number  of  applicants  examined  in  one  year. . .     118,900 

2.  Total  number  employed  having  disabilities  that  did 

not  interfere  with  selected  work 41,158  or  34.7  per  cent. 

3.  Total  number  rejected  for  work  because  of  disabilities  11,433  or  9.7  per  cent. 

4.  Total  number  having  no  disabilities  of  any  moment.  66,309  or  55.6  per  cent. 

5.  Total   number   of   regular   employees   in  these   ten 
industries 102,400 

It  is  fair  to  assume  that  these  11,433  apphcants  who  were  rejected 
for  work  would  have  soon  lost  their  positions  because  of  inefficiency, 
or  would  have  quit  because  of  sickness.  Certainly  by  the  end  of  a 
year  practically  all  of  these  would  have  been  eliminated  from  the  work- 
ing force.  It  is  impossible  to  accurately  estimate  what  the  loss  to  these 
concerns  would  have  been  during  that  year  from  having  these  men 
and  women  in  their  employ.  It  would  have  been  considerable,  how- 
ever, from  decreasing  efficiency  due  to  the  disease,  from  an  increased 
accident  rate,  from  loss  of  time  due  to  sickness  and  the  resulting  sick 
benefits  in  many  cases. 

Several  estimates  have  been  made  of  the  cost  of  labor  turn-over. 
These  are  based  on  the  cost  of  employing  people,  teaching  them  the 
job,  and  the  time  elapsing  before  they  become  efficient  or  productive. 
These  estimates  vary  from  $10.00  to  $200.00.  One  authority,  after  a 
careful  study  of  this  problem  in  many  industries,  gives  as  a  low  average 
the  amount  of  $35.00  as  representing  the  cost  of  hiring  and  training 
an  individual.^ 

Therefore,  these  11,433  rejected  cases  can  be  estimated  as  saving 
these  concerns  $400,155  in  labor  turn-over. 

Magnus  Alexander  in  a  comprehensive  study  of  the  cost  of  health 
supervision  in  ninety-nine  different  industries  found  that  the  average 
cost  per  employee  for  all  medical  work  was  $2.50.  Using  this  figure 
as  a  fair  average,  and  taking  the  regular  number  of  employees  as 
102,400,  we  can  estimate  the  cost  of  the  entire  medical  work  in  these 
ten  industries  at  $256,000. 

Thus  the  examination  of  applicants  alone  undoubtedly  saved  these 
concerns  over  $140,000  during  the  course  of  one  year. 

Table  6 

1.  Saving  to  ten  concerns  from  rejection  of  physically  unfit $400,155 

2.  Cost  of  entire  medical  work  in  these  concerns 256,000 


3.  Profit  to  the  concerns  from  this  one  branch  of  medical  work  alone.  .  .    $144,155 

It  is  fair  and  conservative  to  estimate  that  at  least  10  per  cent, 
of  those  applicants  with  physical  disabilities,  who  were  employed, 
1  A  more  recent  estimate  places  this  at  $45.00. 


BENEFITS    AND    PROFITS    OF    THE    MEDICAL   DEPARTMENT      89 

would  have  quit  very  shortly  if  physical  selection  of  the  proper  job  had 
not  been  used,  thus  adding  to  their  efficiency,  contentment  and  health 
protection.  This  adds  another  $144,000  to  the  profit  of  the  em- 
ployers from  this  system. 

While  the  above  figures  can  only  be  estimated,  yet  the  most  skep- 
tical must  surely  agree  that  the  examination  of  applicants  for  work,  and 
the  rejection  of  the  physically  unfit,  even  when  based  on  the  most 
humane  standards  for  rejection,  certainly  pays  any  concern  adopting 
this  method.  And  the  saving  to  that  concern  from  his  procedure 
alone  will  more  than  pay  the  costs  of  the  most  efficient  Human  Main- 
tenance Department  they  can  establish. 


1  CHAPTER  VIII 

COST  OF  THE  MEDICAL  DEPARTMENT 

In  the  preceding  chapter  an  endeavor  was  made  to  show  the  profit 
which  a  concern  derives  from  its  human  maintenance  department  and 
to  point  out  the  difficulty  of  obtaining  actual  figures  on,  this  subject. 
The  cost  of  maintaining  such  a  department  is  of  equal  interest.  In 
fact,  it  is  very  essential  for  an  industrial  surgeon  to  have  a  clear  con- 
ception of  costs  in  making  recommendations  to  an  employer  con- 
templating extending  the  medical  and  surgical  work  in  his  plant. 

Naturally  the  cost  of  such  a  service  depends  upon  many  factors. 
Chief  among  these  are : 

1.  The  caliber  of  the  physicians  employed. 

2.  The  number  of  physicians  on  the  staff. 

3.  The  number  of  hours  the  physicians  are  engaged. 

4.  The  use  of  outside  medical  and  surgical  service. 

5.  The  number  of  industrial  nurses. 

6.  The  number  of  clerks,  stenographers  and  other  lay  assistants. 

7.  The  number  of  employees  in  the  concern. 

8.  The  comprehensiveness  and  thoroughness  of  the  medical  and 
surgical  work. 

9.  The  amount  of  medical  and  surgical  supplies  used. 

10.  The  extent  to  which  laboratory  and  rc-ray  methods  are  em- 
ployed. 

It  is  quite  evident  that  in  estimating  the  cost  of  this  health  service 
each  of  the  above  factors  must  be  considered  in  connection  with  each 
individual  concern.  However,  certain  facts  and  figures  can  be  given 
which  will  be  of  assistance  in  estimating  cost. 

The  Caliber  of  the  Physicians  Employed.— This  is  one  of  the  most 
important  considerations  for  the  success  of  the  work  and  the  effi- 
ciency with  which  it  is  done.  All  industries  will  find  it  more  effective 
and  much  more  economical  in  the  long  run  to  employ  the  best  medical 
and  surgical  talent  which  they  can  secure.  By  this  I  do  not  mean 
highly  specialized  physicians  to  represent  each  particular  specialty  of 
medicine  in  their  plant  hospitals,  but  broad-minded,  well -trained,  all- 
around  physicians.  In  addition  these  doctors  should  have  a  highly 
developed  sociological  sense  and  should  be  filled  with  enthusiasm  for 
the  service  which  they  can  render  to  their  fellowmen.  The  oppor- 
tunity for  service  is  offered  to  a  greater  extent  in  industrial  practice 

90 


COST    OF   THE    MEDICAL   DEPARTMENT  91 

than  in  any  other  line  of  medicine.  It  is  true  that  the  cost  of  em- 
ploying this  type  of  physician  is  considerably  more  than  to  employ 
a  mediocre  doctor,  but  the  efficient  service,  the  vision  to  develop  a 
truly  human  maintenance  system,  and  the  saving  in  life  and  limb  will 
more  than  compensate  for  this  initial  expense, 

A  number  of  large  industries  have  chief  surgeons  of  this  caliber. 
Some  of  these  men  devote  their  entire  time  to  the  work  while  others 
give  only  a  part  of  their  time.  The  salaries  paid  these  full-time  men 
vary  from  $4000  to  $15,000  annually.  The  part-time  men  draw 
annual  salaries  from  $2000  to  $10,000  depending  largely  upon  the 
amount  of  time  devoted  to  the  work. 

Industrial  concerns  cannot  expect  to  secure  well-trained  physi- 
cians at  a  lower  salary.  In  fact,  as  our  better  surgeons  take  up  this 
work  employers  are  found  to  be  paying  greater  salaries.  "While  the 
opportunity  for  service  is  abundant  in  industries,  yet  human  nature 
is  such  that  the  majority  desire  to  be  paid  for  this  service.  Men  who 
have  devoted  eight  and  ten  years  preparing  for  their  life  work  at  a 
very  great  cost  naturally  will  seek  that  line  of  work  most  remunerative. 

Too  many  industries,  in  the  past  and  even  at  the  present  time,  are 
employing  company  surgeons  who  have  failed  to  make  a  success  of 
the  practice  of  medicine  or  who  do  not  desire  to  put  forth  the  strenuous 
effort  necessary  to  make  a  success.  They  are  paying  these  men  $150 
to  $250  a  month  for  their  full  time  but  frequently  fail  to  get  value 
received. 

Not  all  the  poorly  paid  industrial  surgeons  belong  in  this  class, 
for  many  a  well-trained  young  man  takes  up  this  work  on  a  small 
salary  simply  as  a  means  of  accumulating  a  little  capital  which  will 
enable  him  to  enter  private  practice  or  some  one  of  the  specialties. 
He  renders  good  service  but  as  soon  as  financially  able  he  relinquishes 
the  industrial  practice.  This  is  a  source  of  great  loss  to  those  concerns 
pursuing  such  a  shortsighted  course. 

The  old  time  company  surgeon  who  accepted  a  small  fee  for  emer- 
gency work  or  took  a  contract,  at  a  low  figure,  to  do  only  the  surgical 
work  for  an  industry,  as  a  rule  rendered  very  inefficient  service  to  the 
employees.  His  standing  in  the  profession  was  of  a  very  low  average 
and  the  character  of  his  work  was  of  a  low  standard.  He  was  a  com- 
pany surgeon  in  word  and  deed  and  too  often  was  only  on  the  side  of 
the  employer  as  represented  by  the  insurance  company.  The  stand- 
ards of  industrial  medical  and  surgical  practices  as  represented  by  these 
men  reached  a  very  low  plane. 

Fortunately  a  few  large  concerns  and  some  of  the  insurance  com- 
panies awakened  to  the  importance  of  efficient  medical  care  for  em- 
ployees and  began  to  pay  for  better  trained  physicians.  These  men 
had  a  vision  of  the  great  opportunities  for  preventive  medicine  and  pre- 


92  INDUSTRIAL    MEDICINE    AND    SURGERY 

ventive  surgery  offered  by  industrial  medicine,  and  during  the  last 
decade  have  developed  this  line  of  practice  into  one  of  the  greatest 
specialties  of  our  profession.  And  with  the  industries  of  the  nation 
devoting  more  and  more  attention  to  the  conserving  of  our  man  power 
this  specialty  will  develop  far  beyond  our  present  dreams.  The  best 
medical  talent  of  the  country  will  be  brought  into  this  line  of  work. 
Their  sole  effort  will  be  devoted  to  the  welfare  of  the  employee,  but 
it  will  be  retroactive  to  the  welfare  of  the  employer.  The  old  type 
employer's  physician  is  passing  and  the  new  era  of  the  employee's 
physician  is  here. 

The  Number  of  Physicians  on  the  Staff  and  the  Number  of  Hours 
Spent  on  the  Job. — Among  the  leading  surgeons  in  industry  opinion 
is  divided  as  to  the  number  of  hours  the  company  physician  should 
spend  on  the  job.  Some  advocate  the  full-time  doctor  while  others 
favor  the  part-time  plan. 

Unfortunately  in' the  past  too  many  of  the  full-time  physicians 
have  been  underpaid,  have  been  held  too  closely  to  the  plant,  pre- 
venting their  scientific  development,  and  have  settled  into  a  "rut." 
Such  a  policy  has  deterred  the  best  trained  men  from  taking  a  full-time 
position.  A  few  industries,  willing  to  pay  for  the  best  of  service, 
have  been  able  to  secure  and  hold  men  of  the  highest  professional 
standing  who  give  their  entire  time  to  this  work.  The  strongest  argu- 
ment for  such  a  plan  is  the  doctor's  undivided  attention  devoted  to 
the  employees. 

Very  few  industries  are  willing  to  pay  a  salary  commensurate  to 
what  a  well-trained,  scientific  physician  can  earn  in  private  practice. 
They  can  secure,  however,  the  services  of  such  a  man  for  part  time, 
leaving  him  free  to  develop  his  special  practice  on  the  outside.  Thus 
doctors  who  have  been  thoroughly  trained  in  every  branch  of  medicine 
and  surgery,  but  who  are  developing  a  specialty,  will  accept  a  part-time 
position.  In  this  way  a  group  of  specialists  can  be  gathered  together 
in  the  plant  hospital,  who  make  a  diagnostic  and  treatment  group  far 
superior  to  the  majority  of  full-time  staffs.  If  they  are  paid  sufficiently 
well  for  this  part-time  work,  most  of  these  men  will  remain  with  the 
concerns  for  years^ — each  succeeding  year  becoming  more  and  more 
valuable  to  them  as  a  specialist. 

The  full-time  staff  will  find  it  necessary  to  consult  outside  special- 
ists more  frequently  than  a  part-time  staff  composed  of  men  thoroughly 
qualified  to  represent  some  special  line  of  practice.  For  example, 
one  large  industry  employs  ten  physicians  including  the  chief  surgeon, 
all  of  whom  spend  three  and  one-half  hours  at  the  plant.  During  this 
time  they  work  at  a  pace  it  would  be  impossible  to  continue  for  the 
entire  day.  Among  these  doctors  are  represented  the  following  special- 
ties :  surgery,  orthopedics,  gynecology,  internal  medicine,  tuberculosis, 


COST    OF    THE    MEDICAL    DEPARTMENT  93 

psychiatry,  dermatology,  and  an  expert  laboratory  man.  They  are 
not  so  highly  specialized,  however,  that  they  are  not  efficient  as 
examiners  and  general  emergency  men.  All  of  them,  from  the  very 
nature  of  the  work,  are  highly  specialized  in  preventive  medicine 
and  preventive  surgery  which  after  ail  is  the  very  backbone  of  indus- 
trial medicine  and  surgery.  It  would  be  financially  prohibitive  for 
this  industry  to  employ  half  of  this  staff  for  full-time  work,  whereas, 
by  the  part-time  system  they  are  able  to  avail  themselves  of  the  best 
type  of  special  service  whenever  needed. 

These  nine  assistants  receive  an  average  of  $150  per  month 
for  the  three  and  one-half  hours  work  per  day  at  the  plant.  They  are 
free  to  care  for  any  member  of  the  family  of  an  employee  but  are  pro- 
hibited from  accepting  as  a  private  pay  patient  any  one  of  the  employees. 
This  is  very  essential  as  it  removes  the  danger  of  a  physician  soliciting 
patients  from  among  those  whom  he  must  advise  to  seek  certain 
medical  or  surgical  remedial  measures.  It  adds  to  the  weight  of 
the  physician's  advice  when  no  ulterior  motive  can  be  connected 
with  it. 

Number  of  Physicians  Needed. — For  a  comprehensive  system  of 
industrial  medicine  and  surgery  at  least  one  full-time  or  two  part-time 
physicians  for  a  thousand  employees  is  necessary.  Three  full-time 
or  five  part-time  physicians  or  eight  part-time  physicians  are  needed 
for  a  working  force  of  8000  to  12,000. 

If  applicants  are  not  examined  for  work  or  if  re-examinations 
are  not  made  frequently,  or  if  other  phases  of  a  comprehensive  sys- 
tem are  not  incorporated  in  the  work,  the  number  of  physicians 
can  be  reduced. 

The  Number  of  Industrial  Nurses  Employed. — These  nurses 
are  the  most  valuable  assistants  to  the  doctors  and  are  necessary 
to  carry  on  any  efficient  system  of  industrial  medicine.  The  above 
estimate  of  doctors  needed  depends  upon  the  employment  of  these 
nurses.  Besides  assisting  the  medical  staff  they  must  act  as  visiting 
nurses  to  the  sick  and  injured  employees.  They  are  the  best  means 
of  constantly  keeping  in  touch  with  the  absent  employees. 

Two  nurses  for  1000  employees  are  essential.  Three  to  four  nurses 
are  needed  up  to  5000  employees.  Five  to  eight  nurses  for  5000  to 
10,000,  and  as  many  as  twelve  nurses  for  at  least  15,000  employees 
will  be  necessary.  If  all  sick  employees  are  to  be  visited,  however, 
the  above  number  of  nurses  should  be  doubled. 

The  number  of  lay  assistants  will  depend  upon  the  complete- 
ness of  the  records  and  files.  Money  expended  for  keeping  up-to-date 
records  on  all  patients  visiting  the  doctor's  office  is  money  well  spent 
by  the  concern.  These  records  furnish  valuable  comparative  data 
from  year  to  year  and  will  enable  the  discovery  of  many  conditions 


94  INDUSTRIAL   MEDICINE    AND    SURGERY 

effecting  the  health  of  employees  which  can  be  corrected.  One 
stenographer  and  one  filing  clerk  are  necessary  for  each  2000  employees. 
In  one  industry  where  from  600  to  800  workers  per  day  visited  the 
doctor's  office  during  the  busy  months  it  was  found  to  be  most  eco- 
nomical to  employ  a  girl  time  keeper  in  the  waiting  room.  It  was 
her  duty  to  stamp  on  the  hospital  pass,  with  a  time  clock,  the  hour 
of  admission  to  the  office  of  every  employee  and  the  hour  of  leaving. 
In  this  way  the  employees  were  seen  in  turn  and  none  were  allowed 
to  waste  an  undue  amount  of  time  waiting  for  the  attention  of  the 
doctor.  On  the  busiest  day  of  last  year  with  an  average  of  four 
doctors  and  eight  nurses  on  the  job  all  the  time  one  employee  passed 
through  the  office  every  half  minute.  Every  one  of  these  were  seen  by 
either  a  doctor  or  nurse,  and  notation  of  what  was  done  placed 
upon  the  employee's  record. 

This  office  employs  eleven  lay  assistants,  girls,  thus  making  pos- 
sible a  system  which  can  efficiently  handle  such  a  large  number  of 
cases.     The  average  salary  paid  these  girls  is  $15  a  week. 

The  total  cost  increases  with  the  number  of  employees  but  as  a 
rule  the  average  cost  of  this  work  per  person  decreases  with  every 
thousand  employees.  This  is  shown  very  well  in  the  accompanying 
table. 

Also,  the  outlay  increases  with  the  hazardousness  of  the  occupa- 
tions. Thus,  the  cost  of  such  a  system  is  greater  in  a  manufacturing 
plant  than  in  a  mercantile  concern.  The  increased  amount  of  surgical 
supplies  alone  is  responsible  for  a  greater  expense. 

The  comprehensiveness  and  thoroughness  of  the  work  depends 
largely  upon  the  caliber  of  the  medical  men  employed.  Good  scien- 
tific physicians  will  demand  and  use  a  laboratory  and  the  x-ray  more 
than  in  a  plant  where  slip-shod  methods  are  tolerated.  All  of  this 
will  increase  the  immediate  costs  but  the  results  obtained  will  far 
more  than  compensate  a  concern  for  the  additional  expense. 

Cost  of  Health  Supervision  in  Industry. — The  Conference  Board 
of  Physicians  in  Industrial  Practice,  composed  of  industrial  surgeons 
representing  many  of  the  largest  industries  of  the  eastern  states,  has 
contributed  much  valuable  material  to  Industrial  Medicine  and  Sur- 
gery. Magnus  W.  Alexander,  Secretary  of  this  Board,  is  responsible 
for  the  compilation  of  the  attached  table  showing  the  cost  of  health 
supervision  in  industries.  The  author  is  indebted  to  Mr.  Alexander 
for  the  privilege  of  reprinting  this  material. 

"The  accompanying  table  presents  data  for  the  year  1916  as  re- 
ported by  ninety-nine  industrial  plants  located  in  fifteen  states.  The 
total  average  number  of  employees  represented  was  495,544;  the 
average  number  per  plant  was  5005,  the  maximum  37,107,  the 
minimum  141. 


COST    OF    THE    MEDICAL    DEPARTMENT  95 

"While  the  average  cost  per  person  as  indicated  in  the  summary,  is 
$2.50,  it  is  not  representative,  as  the  total  cost  on  which  the  average 
is  based  includes  that  of  four  plants  (71,  85,  95  and  96)  which  render 
unusual  service,  giving  both  medical  and  surgical  attention  to  their 
employees  at  the  plant  and  in  their  homes  as  well,  besides  assuming 
the  medical  care  of  employees'  families.  Omitting  these  four  plants 
from  consideration,  the  average  cost  for  the  479,634  employees  in  the 
other  95  plants  was  $2.21. 

"A  total  of  3,165,114  cases  was  reported,  an  average  of  more  than 
six  cases  per  person  employed,  at  an  average  cost  of  thirty-nine  cents  per 
case.  The  number  of  cases  reported,  however,  does  not  include  all  of 
the  service  rendered.  In  many  plants,  no  record  is  kept  of  slight  injuries, 
of  injuries  redressed,  of  medical  cases  treated,  of  home  visits  made,  or 
of  physical  examinations.  In  others,  even  the  most  trivial  cases  are 
counted.  Furthermore,  as  'cases'  are  so  varied  in  gravity  and  in 
the  time  required  for  treatment,  any  comparisons  of  costs  per  case 
are  not  of  much  value. 

"The  'Total  Medical  and  Surgical  Cost'  includes  salaries  of  physi- 
cians and  nurses,  cost  of  outside  medical  and  surgical  service  and  cost 
of  medical  and  surgical  supplies,  whether  or  not  paid  for  by  insurance 
companies  as  a  part  of  the  insurance  contract;  it  excludes  all  compensa- 
tion for  injuries,  all  overhead  expenses  and  any  wages  paid  to  em- 
ployees while  off  duty  to  have  their  injuries  treated. 

The  chief  significance  of  this  data,  from  a  general  viewpoint,  is 
that  it  is  possible  to  give  such  a  large  amount  of  medical  and  surgical 
service  at  a  cost  which  averages  only  $2.21  per  employee  per  year. 

Convincing  proof  of  the  economic  value  of  health  supervision  in 
industry  is  afforded  by  the  fact  that,  when  collecting  the  data  con- 
tained in  this  report,  it  was  found  that  no  employer  had  abandoned 
the  health  supervision  activities  established  in  his  plant.  On  the  con- 
trary, the  prevailing  tendency  has  been  to  invest  even  more  money 
in  extending  the  service." 


96 


INDUSTRIAL   MEDICINE    AND    SURGERY 


Table  7. — Cost  of  Health  Supebvision. 


QCU] 


1.244 
1,561 
1,730 
1,92S 
2,000 

2,200 
2,400 
2,565 
2.G00 


5        f< 

1  hJ  S 


s  1  M.,  1 F. 
Yes  1  F, 
0     2M.,1F. 


7,922 
8,000 
10,000 
11,000 


1,321 
2,653 
2,700 
4,,500 


-3,050 
4,782 
4,850 


1.000 
1.060 
1,908 
6,603 

1.200 
1.500 
2.500 
3.000 
6,450 


1  3  hrs,  djily 

0 

0 

1   1  hr.  daily 


1.294 
7.200 
6.657  . 
1.623 
4,596  ( 


6.522 
2.360 
1.10!)  (I 
3.968 
16,992  . 

14,394 
10.680  , 

6.194 
15.659 

S.IM 

8.122 
1.327 
23.112 
17,516  . 
11,177 

9,600 
32,160  (' 
53,006 
29,626  . 
12,200 

55,728  (' 


1  2  hrs. 

1  4  hrs. 

3  3  hrs. 

t  3  hrs.  daily 


4,944 
4,843 


18,M4 
30,500 
9,360 


3.826 
4,872 
6,416 


7,254 
2,745 
42,972 
39,931  . 
24,502 

32.000 
36.676 
62,891  ( 
71,914  . 
32,3M 


6.538 
37,746 

8,092 
37,492 
40,642 
40,602 
60,000 


2,800 

0 

1,500 


11,697 
15.413 
5,934 


10.835 
3.303 
8,207 
5,200 
6,225 

7,147 


1,278 
'  5,666 


4,992 
6,274 
2.006 
3,341 
2,679 

10.624 
12,960 
10.458 
10.332 
4,080 

1.294 
11.400 
17,820 

4,600 
28,208 

7,6SS 


7,000 
23,136 
1,970 

6,388 
15,665 
25,458 


16,000 
5,749 
15,648 


21,800 
21,362 
^  5,780 
14,244 
39,044 

41,586 
24,580 
21,087 
95,110 
11,915 


102,616 
57,447 
56,242 


186,170 
107,289 
62,064 


1,754 
4,746 
11,314 
11,072 
1,307 


1,709 

885 

7,140 


2,651 
3,112 
6,744 


1.038 
3.160 
5,878 

4,040 
1,332 
3,485 
4,939 
2.330 


7,517 
3,550 
8,820 
10,980 

11.376 
15.494 
5.157 
6.728 
8,272 


l.."00 
10.369 
6.200 


1,020 
1.250 
7,810 
9,400 


13,253 
48.752 
12.336 
53.987 
53.492 
86,551 
90,200 

2,832 

617 
7,865 
5,721 
6.257 
18.910 
8.564 
1,112 

4.050 
7,253 
27,497 
33.327 
0,461 

1,132 
■15,118 

7,017 
17,813 

8,401 
29,173 

22.40) 


5,940 
41,169 
22,010 


7.074 
7,713 
9.616 
19.897 
9,002 

14.997 
18,897 
17,680 
17,267 
13,641 

30,200 
32,961 
28,749 
34,409 
22,650 

21,6 
87,717 

4,130 
9,113 
5,606 
16,081 
11,010 
36,104 
65,000 

6,932 

2,020 
8,200 
10,700 
5,959 
28,923 
12,919 
23,880 

3.105 
5,155 
19,212 
29,507 
12,654 


14,182 

5,100 
2,835 
9,018 
10,072 
12,550 

2.41 


S5.00 
1.38 

3.es 

4.09 
~  7.40 

1.43 
2.10 
t.U4 

2.87 


1.S8 
1.17 
3.17 

1.4S 

2.31 
1.01 


1.77 
1.67 
1.07 

2.08 
2.09 
1.71 
2.04 
1.30 


S.13 
3.43 

2.ns 

3,S7 


4.S0 
1.89 
3.61 
3.3« 
2  30 

1.49 
3.91 
1.09 


1.000 
1.350 
2.000 
4,589 


■  3,217 
2.45! 


2cri  .Ideam 
t'n'dtlsK 


1  first  aider 


1,443 
7,430 


2,184  . 
1,032 


8,000 

288 

5,800 


3,600 

0 

1,528 


27,673 

0 
1,512 


2,842 

62,128 

131,898 

1,720 
4,173 
4,826 


1,563 
6,2,50 
5,361 
12.000 


56 
3,417 

4,637 

35,590 

130,000 


1.89 

('•)  14.24 

('•)  11.82 

1.47 
2.S9 
2.»0 


COST    OF    THE    MEDICAL    DEPARTMENT 


97 


SUMMARY 

INDUSTRY 

Nombor  ot 
llcprcscntcU 

Averngc  Number 
o(  Employcca 
Supervised 

o(°iii  kSS 

Total  Mediol 

aod  Surgical 

Cost 

AveraB*  Annual 

and  Suriiical 
Supervision 
per  Employee 

47 
7 
1 
7 
5 
6 
5 
5 
4 
2 

1 
1 
1 
3 
99 

291,646 
49,317 
1,270 
24,921 
33,795 
10,572 
13,050 
27,402 
8,939 
4,023 
3,026 
3,358 
2,454 
2,500 
11,000 
2,611 
495,644 

1,988,991 

358,574 

2,832 

49,046 

81,591 

78,744 

09,565 

234,069 

67,380 

10,255 

9,440 

0,742 

2,842 

02,126 

131,898 

11,019 

3,16S,1U 

8541,771 

137,047 

,            6,932 

92,001 

09,033 

34,797 

39,875 

76,089 

24,177 

29,035 

0,102 

3,473 

4,637 

35,590 

130,000 

6,126 

$1,238,486 

$1.84 

2.78 

5.46 

3.72 

1.96 

3.29 

2.92 

2.77 

2.70 

7.37 

2.02 

1.03 

1.89 

('•)  14.24 

(")n.82 

■      2.35 

•$2J0 

Smelting  and  Rc6ning 

ChemicaU 

Coal  and  Iron  Mining 

*Thc  average  annual  cost  per  employee,  excluding  Plants  Nos.  71,  85,  95,  and  96,  for  which  the  cost  includes  sickness 

CHAPTER  IX 
SUPERVISION  OF  THE  HEALTH  OF  THE  MANAGERIAL  STAFF 

The  human  maintenance  department  should  not  be  operated  only 
for  the  employees;  the  managerial  staff  of  the  concern  should  likewise 
be  included  in  its  scope.  The  supervision  of  the  health  of  the 
president,  the  vice-president,  the  general  manager,  and  of  all  the 
department  managers  is  of  equal  or  greater  economic  importance  to 
the  industry. 

Every  industrial  surgeon  agrees  that  the  success  of  his  work  de- 
pends upon  interesting  the  head  of  the  concern  and  securing  his  co- 
operation. Many  surgeons  insist  upon  reporting  direct  to  the  chief 
executive,  or  his  highest  representative,  depending  upon  this  as  the 
best  means  of  securing  the  indorsement  and  assistance  of  the  managers. 

Too  often  the  physician  fails  to  take  advantage  of  this  opportunity 
by  neglecting  to  offer  this  medical  supervision  to  the  managerial  force. 
On  the  other  hand,  the  attitude  of  these  managers  is  often  incon- 
sistent. They  will  lend  every  assistance  toward  extending  the  work 
to  the  employees  but  refuse  to  apply  it  to  themselves. 

Some  executives  and  managers  have  adopted  the  principle  that  all 
work  and  no  play  does  not  pay  dividends  and  for  these  the  supervi- 
sion is  not  so  essential.  But  the  majority  of  busy  business  men  are 
over-burdened  with  work,  are  irregular  in  their  habits,  eating  at  all 
hours,  sleeping  too  little,  and  failing  to  take  sufficient  exercise.  They 
work  at  high  tension  and  develop  a  high  tension  machine.  They 
depend  upon  their  few  weeks'  vacation  once  a  year  in  which  to  recu- 
perate their  wasting  energies. 

None  of  these  practical  business  men  would  think  of  working  an 
expensive,  high  powered  machine  day  in  and  day  out  without  peri- 
odically inspecting  it  and  repairing  damaged  parts  before  the  machine 
was  ruined.  They  should  give  the  same  attention  to  the  human 
mechanism. 

Many  of  these  men  develop  circulatory  conditions  or  damaged 
nervous  systems  which  totally  unfit  them  for  further  service,  often 
prematurely.  In  this  way  the  concern  suffers  the  loss  of  a  valuable 
executive — &  loss  which  the  industrial  surgeon  might  prevent. 

Therefore,  the  medical  staff  should  extend  its  work  to  include 
everybody  from  the  president  of  the  concern  down  to  the  lowest  em- 

98 


SUPERVISION    OF   HEALTH    OF    MANAGERIAL    STAFF  99 

ployee.  In  a  few  places  this  is  done  with  the  result  that  the  manage- 
rial staff  sets  the  example  for  the  rank  and  file  of  the  employees.  When 
it  is  necessary  for  the  entire  force  to  be  vaccinated  the  president  and 
general  manager  are  the  first  to  submit  to  the  operation.  When  the 
president  and  the  managers  undergo  a  periodical  medical  examina- 
tion and  talk  about  it  freely  it  is  an  easy  matter  to  win  over  the  rest 
of  the  force  to  such  a  procedure  and  to  gain  their  confidence.  But 
aside  from  the  example  it  is  of  the  greatest  value  to  these  executives 
to  develop  habits  of  prevention.  They  owe  it  to  themselves,* to  their 
families  and  to  the  business  which  they  represent. 

The  periodical  medical  examination  and  the  resulting  health  super- 
vision should  be  applied  to  the  executives  and  all  the  department 
managers  of  every  industry.  At  least  twice  a  year  these  officials 
should  be  thoroughly  examined;  this  should  include  urinalysis  and 
blood-pressure  tests.  If  the  examination  reveals  the  need  of  a  more 
thorough  study,  the  same  should  be  made  at  once.  It  is  necessary 
to  maintain  a  tickler  system  on  these  officials,  calling  them  to  the 
office  for  examination  when  their  turn  arrives.  This  should  not  be 
left  to  their  memory. 

Great  care  and  diplomacy  must  be  exercised  in  telling  these  men 
of  any  little  condition  which  is  found  and  which  needs  some  correct- 
ive treatment.  These  officials  very  frequently  become  panicky  over 
some  minor  condition,  developing  a  real  neurasthenia  because  of  the 
suggestion  contained  in  some  warning  which  the  doctor  gives.  This 
is  often  truer  of  managers  than  of  the  employees  in  the  ranks.  It 
may  be  due  to  the  high  tension  at  which  they  live  and  work,  or  to  the 
responsibilities  which  rest  upon  them,  or  more  probably  to  the  fact 
that  they  can  afford  to  go  from  doctor  to  doctor,  trying  to  find  one 
who  will  confirm  their  worst  fears. 

The  case  of  Manager  P.  illustrates  this  point  very  forcibly.  On 
the  managers'  tickler  system  it  was  Mr.  P.'s  day  to  be  examined.  He 
was  called  to  the  office  and  the  physical  examination  made  which 
showed  Mr.  P.  perfectly  normal  physically.  However,  he  was  tired 
and  nervous  and  complained  of  stomach  trouble.  In  a  manner  he 
censured  the  doctor  for  not  discovering  the  condition. 

Undiplomatically  the  company  physician  said,  "Well,  you  had 
better  go  and  have  a  stomach  analysis  made." 

Instead  of  following  up  the  case  and  reassuring  this  tired  manager 
the  doctor  let  him  depart  unsatisfied. 

Mr.  P.  went  to  his  family  physician  who  did  not  make  a  stomach 
analysis  but  who  agreed  with  his  patient's  diagnosis  of  stomach  trouble. 
Mr.  P.  was  not  satisfied,  however,  because  he  was  still  thinking  of  that 
"stomach  analysis"  suggested  by  the  company  doctor. 

He  finally  went  to  a  specialist  who  for  $25  made  the  analysis  and 


100  INDUSTRIAL   MEDICINE    AND    SURGERY     e 

while  it  failed  to  show  anything  definite  yet  the  specialist  suggested 
further  study  to  rule  out  the  possibility  of  cancer.  Poor  Mr.  P.  became 
panicky  and  started  to  jump  from  doctor  to  doctor  most  of  whom 
reassured  him  and  laughed  at  his  fears.  He  was  unconsciously  looking 
for  the  doctor  who  would  agree  with  his  own  diagnosis  of  his  case. 
After  three  months  the  general  superintendent  of  this  concern  called 
up  the  company  surgeon  and  asked  what  was  the  matter  with  manager 
P.  who  was  falling  down  in  his  work  and  whose  department  was  going  to 
pieces.  ° 

The  doctor  had  not  seen  Mr.  P.  for  three  months  but  he  would  do 
so  at  once. 

Mr.  P.  was  called  to  the  office.  After  two  weeks  of  careful  study, 
and  patiently  demonstrating  to  the  man  that  he  did  not  have  a  cancer, 
the  doctor  was  able  to  enter  into  the  status  of  the  case  at  the  point 
where  he  should  have  started  three  months  previously  at  the  first 
examination. 

Mr.  P.'s  first  symptoms  were  tiredness,  nervousness  and  a  "funny, 
sick  feeling"  in  the  stomach.  The  doctor  after  gaining  his  confidence, 
found  that  the  production  in  his  department  had  fallen  off,  that  the 
general  superintendent  had  had  Mr.  P.  "on  the  carpet"  a  number  of 
times,  causing  fear  of  losing  his  job.  This  fear  was  the  etiologic  factor 
and  beginning  of  his  entire  trouble. 

The  general  superintendent  when  informed  of  the  condition  re- 
moved the  fear,  a  short  vacation  was  prescribed  which  was  spent  at 
hard  work  on  a  farm,  and  Mr.  P.  returned  a  month  later  a  well  man 
and  with  no  thought  ever  given  to  whether  he  had  a  stomach  or  not. 

Not  only  the  managers  but  all  the  employees  learn  to  lean  upon  the 
medical  staff  for  advice  and  guidance  concerning  their  health.  Many 
foolish  fears  and  symptoms  are  brought  to  the  attention  of  these  doc- 
tors. Every  case  must  be  considered  carefully  and  seriously  treated, 
no  matter  how  trivial  it  may  seem  to  the  doctor.  Only  in  this  way 
can  you  avoid  the  panic  which  overcame  Mr.  P.  and  the  resulting 
economic  loss  to  his  industry. 

Besides  examining  and  advising  these  managers  on  health  mat- 
ters the  medical  staff  should  take  an  interest  in  seeing  that  healthful 
recreation  and  exercise  is  provided  for  them  as  well  as  for  the  em- 
ployees. Some  concerns  insist  on  their  managers  taking  one  afternoon 
a  week  to  play  golf.  Others  provide  tennis  courts  about  the  plant 
grounds  for  the  use  of  the  managers.  These  arrangements  are  of 
great  aid  in  the  months  when  least  needed.  In  the  winter  months  the 
lack  of  healthful  exercise  is  most  apparent.  Steps  should  be  taken  by 
every  concern  to  meet  this  condition. 

One  industry  has  provided  a  gymnasium  for  its  executive  and 
managerial  staff.     This  gym  contains  the  usual  apparatus  for  exercise,  a 


SUPERVISION    OF    HEALTH    OF    MANAGERIAL    STAFF  101 

shower  bath,  needle  bath,  electric  cabinet  and  table  for  a  thorough  rub 
down.     A  physical  director  is  in  attendance  at  all  times. 

The  managers  have  their  regular  period  each  day  for  reporting  here 
for  a  short  work  out.  The  president  and  vice-president  of  this  concern 
are  the  most  faithful  followers  of  this  plan  and  use  their  influence  to 
see  that  every  manager  takes  advantage  of  the  gymnasium. 

Supervision  of  the  health  of  the  managerial  staff  should  be  a  very 
definite  part  of  the  work  of  the  industrial  physician  and  surgeon  in 
every  concern.  It  will  do  more  than  anything  else  to  prevent  the 
frequent  and  unnecessary  nervous  breakdowns  which  are  entirely  too 
prevalent  among  the  busy  business  men  of  to-day. 


CHAPTER  X 

RECREATION  AND  EXERCISE  AS  RELATED 

TO  SUPERVISION  OF  HEALTH 

OF  EMPLOYEES 

In  many  up-to-date  industries  much  attention  is  devoted  to  proper 
recreation  and  physical  exercise  for  the  employees.  This  is  true  in 
industries  where  medical  departments  have  never  been  installed.  In 
others  with  excellent  medical  staffs  this  health  adjunct  is  neglected; 
or,  if  it  exists,  it  is  not  considered  in  any  way  related  to  the  medical 
service.  Too  often  the  provisions  for  recreation  and  playgrounds 
are  left  to  the  welfare  department  or  to  employees'  committees,  and 
the  plant  physicians  take  no  interest  in  the  work. 

No  better  health  movement  can  be  inaugurated  by  any  concern  for 
its  employees  than  by  providing  proper  facilities  for  recreation  and 
exercise  in  close  proximity  to  the  working  place.  Besides  proving  of 
healthful  benefit  such  an  interest  displayed  by  the  employers  tends  to 
create  a  loyalty  and  good  fellowship  among  the  employees  themselves. 

In  all  industries  the  medical  departments  should  take  a  very  active 
part  in  the  formation  and  maintenance  of  all  movements  for  the  rec- 
reation and  physical  exercise  of  employees. 

These  recreational  movements  have  taken  many  and  varied  forms. 
In  some  cases  they  are  not  only  for  the  benefit  of  the  employees  but  for 
their  families  likewise.  Their  purposes  are  diversional,  educational, 
healthful  and  to  develop  loyalty  toward  the  industry.  They  are  carried 
on  in  connection  with  the  plant  itself,  in  the  grounds  about  the  plant, 
in  halls  provided  for  the  purpose,  in  Y.  M.  C.  A.'s,  or  gymnasiums  built 
near  the  plant,  and  may  be  extended  to  the  schools  and  churches  of  the 
community  where  the  industfy  is  the  means  of  stimulating  them. 

The  following  examples  of  recreation  for  the  employees  are  more 
purely  diversional  and  educational  and  therefore  are  not  so  closely 
related  to  the  medical  department.  Activity  in  them  by  the  doctors 
and  nurses,  however,  increases  the  influence  and  standing  of  the  medical 
staff  with  both  the  employees  and  employers. 

Motion  picture  shows. 

Picnics  for  the  employees. 

Boat  and  train  excursions. 

Lectures  and  concerts. 

Dances  and  parties. 

102 


RECREATION    AND 


EXERCISE    OF   EMPLOYEES 


103 


:'y(?4 


A 


104 


INDUSTRIAL    MEDICINE    AND    SURGERY 


RECREATION    AND    EXERCISE    OF    EMPLOYEES  105 

Sewing  and  cooking  classes. 

Libraries  and  plant  journal. 

Advantage  can  be  taken  of  the  motion  picture  shows,  the  lectures 
and  the  plant  journal  as  a  means  of  injecting  snappy  health  talks 
or  demonstration  of  disease  and  accident  prevention  methods  into  the 
minds  of  the  employees.  These  are  very  effective  measures  especially 
when  introduced  as  a  part  of  a  purely  recreational  program. 

The  recreations  tending  to  improve  the  health  of  the  employees  are 
the  ones  in  which  the  medical  staff  should  take  the  greatest  interest. 
These  are: 

1.  Physical  Drills  or  Exercise  Conducted  During  Working  Hours. — 
Much  benefit  is  gained  for  employees  and  their  working  capacity  is 
increased  especially  where  their  work  is  sedentary,  if  ten  minutes  every 
two  hours  are  devoted  to  physical  exercise. 

The  windows  should  be  thrown  wide  open  and  the  employees  put 
through  a  drill  or  calisthenic  movements.  Deep  breathing  exercises 
should  always  be  included.  Every  department  manager  should 
be  given  instructions  in  proper  exercises  by  a  well  trained  physical 
director  so  he  or  she  can  conduct  these  recreational  periods.  There 
is  nothing  which  tends  to  overcome  the  loss  of  efficiency  from  fatigue 
as  much  as  this.  The  employees  should  be  urged  to  go  through 
similar  setting  up  exercises  on  arising  in  the  morning. 

2.  The  Recreation  Room. — Many  industries  have  built  in  connec- 
tion with  their  plants  large  club  rooms — one  for  women  and  one  for 
men.  Here  reading  and  writing  rooms  are  provided,  gymnasiums 
with  all  kinds  of  appliances  are  furnished  and  the  rooms  may  be  used 
as  meeting  halls  for  shows,  lectures,  dances,  etc.  The  doctor  should 
stimulate  the  physical  exercise  features  of  these  recreational  rooms. 
He  should  also  see  that  they  are  light,  airy  and  clean  at  all  times 
(Fig.  18). 

Often  a  prescription  providing  for  certain  hours  spent  in  the  gym 
wiU  do  far  more  toward  overcoming  some  threatened  disease  or  break- 
down in  an  employee  than  a  prescription  for  iron,  quinine  and  strych- 
nia. In  fact  the  more  of  these  healthful  adjuncts  the  physician  can 
add  to  his  armamentarium  the  less  drugs  will  he  dispense. 

3.  The  Playgrounds  and  Athletic  Fields. — Om-  colleges  were  the 
first  to  recognize  an  athletic  field  as  a  definite  and  essential  part  of 
the  educational  plant.  To-day  many  industries  have  adopted  the  idea 
and  have  provided  ball  grounds,  tennis  courts,  cinder  tracks,  and  all 
the  appliances  that  make  up  a  regular  athletic  field  (Fig.  19).^ 

Teams  are  organized  in  various  departments  and  compete  with 
one  another.  Much  friendly  rivalry  is  developed.  The  silver  cups 
won  by  department  teams  in  tennis,  the  baseball  pennants  won,  and 

^  Figs.  17  to  19  by  courtesy  of  Sears,  Roebuck  &  Co. 


106 


INDUSTRIAL   MEDICINE    AND    SURGERY 


RECREATION    AND    EXERCISE    OF    EMPLOYEES  107 

the  individual  medals  and  prizes  stimulate  these  athletic  contests 
and  make  them  very  popular  with  the  employees. 

These  provisions  for  outdoor  athletics  are  of  great  aid  to  the  med- 
ical department.  Many  a  hollow  chested,  shallow  breathing,  stoop 
shouldered  employee  who  is  frequently  absent  on  account  of  minor 
ailments  can  be  broadened  out  into  a  well  man  by  persuading  him  to 
use  the  athletic  field.  Many  of  these  boys  began  work  very  young 
and  never  had  the  advantages  of  athletic  training  at  school  or  college. 
They  enter  into  the  sport  with  all  the  enthusiasm  of  a  freshman. 

Besides  invigorated  bodies,  their  minds  are  benefited.  For  the 
first  time  the  spirit  of  perseverance  and  conquest  is  instilled  into  them. 
The  joy  of  winning  on  the  athletic  field  is  an  incentive  to  strive 
to  win  in  life's  competition.  These  athletic  contests  should  receive 
the  most  enthusiastic  backing  from  the  medical  department  of  the 
industry.  The  doctor's  responsibility  for  the  men  entering  these 
strenuous  exercises  should  always  be  kept  in  the  foreground.  No 
man  should  be  allowed  to  enter  a  contest  on  the  athletic  field  without 
undergoing  a  thorough  physical  examination. 

One  large  industry,  with  which  the  writer  was  connected;  has  as 
complete  an  athletic  field  as  any  university  in  the  land.  This  consists 
of  a  quarter  mile  cinder  track,  baseball  diamonds,  fourteen,  tennis 
courts,  and  all  the  paraphernaHa  for  a  complete  field  day,  as  hurdles, 
jumping  and  pole  vaulting  standards,  etc. 

Every  year  a  field  day  meet  is  held  with  at  least  300  entries.  The 
preliminaries  may  be  held  the  week  preceding  the  meet.  The  attendance 
at  these  meets  is  from  12,000  to  15,000  people. 

Besides  the  track  teams,  this  concern  has  twelve  regular  ball 
teams,  and  innumerable  pick  up  teams  for  ball  games  at  the  noon 
hour  or  in  the  evening.  Hundreds  of  employees  take  advantage  of 
the  tennis  courts.  All  of  these  athletes  are  thoroughly  examined  hj 
the  medical  staff  before  being  allowed  to  participate  in  the  training  for 
these  contests  or  to  join  a  team.  Many  a  man  with  an  unknow^n 
heart  lesion,  a  beginning  lung  condition,  a  hernia,  or  some  other  early 
defect  is  discovered  in  this  way.  For  these  the  strenuous  athletic 
sports  would  have  been  detrimental  and  in  many  cases  absolutely 
dangerous. 

Therefore,  while  physical  exercise  may  be  a  great  boon  to  the 
employees  and  may  be  a  favorite  prescription  for  the  doctor  to  give, 
yet  it  should  never  be  prescribed  without  previously  examining 
your  patient  and  selecting  the  proper  type  of  exercise  and  the  amount 
of  the  dose. 

These  examinations  are  thorough  from  head  to  foot  and  always 
include  a  urinalysis  and  other  laboratory  tests  when  needed.  College 
athletes  are  supposed  to  be  examined  before  entering  into  similar 


108  INDUSTRIAL    MEDICINE    AND    SURGERY 

contests,  but  with  only  four  or  five  exceptions  no  college  or  university 
submits  their  athletes  to  an  examination  that  is  worthy  of  the  name. 
On  £,ccount  of  this,  great  damage  is  done  to  the  physical  make-up  of 
many  of  our  college  youths. 

A  wonderful  .opportunity  is  given  to  the  industrial  physician  to 
introduce  healthful  exercise  and  athletic  contests  among  millions  of 
boys  and  girls  and  men  and  women  throughout  our  country.  But  in 
doing  this  they  should  impress  upon  the  people  the  importance  of 
examining  the  machine  before  undertaking  the  strenuous  work. 

Universal  military  training  would  be  a  mighty  boon  to  the  health 
of  our  young  manhood  because  it  would  be  accompanied  with  medical 
examinations  and  the  type  and  amount  of  drill  would  be  on  a  select- 
ive physical  basis.  The  stimulating  of  athletics  among  employees, 
if  based  on  a  similar  plan  of  physical  selection,  would  be  equally 
beneficial. 

A  comprehensive  human  maintenance  department  therefore  must 
include  in  the  scope  of  its  work  these  recreational  provisions. 


CHAPTER  XI 
FOOD 

Food  is  one  of  the  most  significant  factors  in  the  maintenance  of 
health.  The  medical  department  of  an  industry  that  pays  no  atten- 
tion to  the  food  of  the  employees  is  neglecting  an  important  duty. 

The  inalienable  right  to  eat  whatever  one  wants  cannot  be  tam- 
pered with  by  any  employer.  Even  the  company  physician  cannot 
prescribe  the  proper  diet  for  employees  and  force  them  to  follow  it. 
But  in  many  subtle  ways  the  physician  can  influence  the  diet  of  a 
large  group  of  people  just  as  he  does  for  an  individual  patient. 

The  responsibility  does  not  cease  with  the  suggestion  of  proper 
food  to  eat  but  deals  more  with  correlated  subjects.  Therefore,  the 
physician  responsible  for  the  health  of  hundreds  of  employees  must 
be  on  the  alert  to  discover  group  defects  in  nourishment  and  quick 
to  find  the  cause  and  remedy  for  the  same. 

In  dealing  with  the  individual  employee  he  can  inquire  into  the 
question  of  diet  and  suggest  corrective  changes  when  needed.  He  can 
ascertain  whether  or  not  the  wages  paid  are  inadequate  to  properly 
nourish  the  employee  and  those  dependent  upon  him.  Often  the 
dependents  are  so  numerous  that  this  becomes  a  real  cause  for  under- 
nourishment and  resulting  sickness.  He  will  discover  certain  con- 
ditions which  are  the  result  of  improper  food,  improper  eating  places, 
irregular  meals,  hasty  consumption,  insufficient  teeth  for  proper 
mastication,  peculiarities  of  diet  detrimental  to  the  individual  and 
many  other  conditions  where  the  food  and  eating  habits  have  a  direct 
bearing  on  the  physical  condition. 

These  faults  are  best  corrected  by  frequently  repeated  advice  to 
the  individual.  He  can  even  take  up  the  question  of  low  wage  with 
the  management,  when  he  feels  that  this  is  the  cause,  and  usually 
have  it  corrected.  Even  a  wrong  diet  at  home  for  the  employee  and 
his  family  can  be  corrected  by  proper  advise  from  the  physician 
assisted  by  the  subtle,  diplomatic  suggestions  of  the  visiting  nurse 
who  drops  in  for  a  friendly  call  on  the  wife. 

But  in  dealing  with  the  entire  group  of  employees  the  industrial 
physician  can  do  many  things,  with  and  ^\ithout  the  assistance  of  the 
employer,  to  influence  the  health  of  the  people  under  him  as  related 
to  food  and  food  conditions. 

109 


110  INDUSTRIAL   MEDICINE    AND    SURGERY 

Talks  to  employees  individually  and  in  groups  concerning  food 
hygiene  will  bear  certain  fruit.  Written  pamphlets  handed  out  from 
the  office  or  distributed  to  the  employees  through  the  pay  envelope 
will  give  further  results  and  are  of  greater  value  because  they  usually 
are  read  by  the  wife  or  mother  at  home. 

After  inquiring  into  the  food  eaten  by  thousands  of  employees,  one 
is  convinced  that  bread,  meat  and  potatoes  are  used  to  excess,  and  that 
milk,  green  vegetables  and  nourishing  soups  are  neglected  by  the 
majority  of  housewives  who  are  responsible  for  maintaining  the  man 
power  of  the  industries  of  the  country.  A  campaign  of  education 
directed  along  these  lines  by  the  medical  staff  will  result  in  great 
benefit  to  the  health  of  the  working  force.  Too  long  has  the  doctor 
neglected  this  power  at  home  which  could  be  directed  into  useful  co- 
operative channels. 

Where  employees  carry  their  lunches  to  work  two  problems  present 
themselves  for  the  attention  of  the  doctor.  First,  a  study  of  the 
food  will  show  that  the  average  lunch  is  far  deficient  in  calories. 
The  writer  has  investigated  hundreds  of  such  lunches  and  the  average 
contains  a  cold  bread  and  meat  sandwich  (the  bread  is  often  a  cold 
biscuit),  a  piece  of  pie  and  a  banana.  This  would  do  occasionally  but 
the  same  thing  day  in  and  day  out  is  not  a  sufficient  lunch  for  a  hard 
working  man.  His  fuel  box  is  not  replenished  at  the  noon  hour  and 
his  efficiency  in  the  afternoon  is  bound  to  suffer.  This  is  not  so  true 
in  smaller  towns  where  the  dinner  pail  is  still  in  use.  But  in  our 
cities  the  dinner  pail  is  out  of  fashion  and  the  small  paper  sack  which 
can  be  stuck  in  the  pocket  has  replaced  it. 

The  second  problem  is,  Where  are  these  lunches  eaten?  The 
majority  of  girls  carrying  their  hmches  will  eat  them  at  their  desks 
and  then  will  spend  the  remainder  of  the  noon  hour  sewing  or  reading. 
Or,  they  will  congregate  in  some  dark  corner  where  the  lunches  are 
consumed,  sitting  there  and  talking  for  the  rest  of  the  hour.  The  men 
will  find  some  secluded  spot,  eat  their  lunch,  and  then  curl  up  for  a  nap 
or  will  sit  inside  and  smoke.  The  incentive  to  get  out  of  the  building 
at  the  noon  hour  and  exercise  in  the  fresh  air  by  walking  somewhere 
for  their  lunch  is  removed  when  it  is  carried  to  work  and  kept  in  the 
desk  or  locker. 

To  correct  these  two  conditions  every  industry  will  find  it 
worth  while  to  provide  lunches  and  proper  eating  places  for  their 
employees. 

The  plant  restaurant  is  a  fixture  in  many  concerns.  The  food 
should  be  excellently  prepared  and  sold  so  reasonably  that  it  would 
be  chosen  in  preference  to  neighboring  restaurants  or  even  to  carrying 
the  lunch.  The  majority  of  concerns  do  not  give  sufficient  attention 
to  the  quality  and  preparation  of  the  food  in  their  restaurants. 


FOOD  111 

The  profit  from  such  a  restaurant  should  not  be  made  from  the  sale 
of  food  but  from  the  more  efficient,  happy,  well  nourished  working  force. 

The  restaurant  should  be  located  outside  the  plant,  forcing  all 
employees  to  go  out  at  the  noon  hour.  A  place  should  be  provided 
in  it  for  those  employees  to  eat  who  carry  their  lunches.  Some 
concerns  serve  milk  and  coffee  to  these  in  order  to  get  them  to  the 
restaurant. 

A  proper  eating  place  should  always  be  provided  and  then  a  rule 
made  and  enforced  by  the  management  that  no  employee  could  remain 
inside  at  the  noon  hour.  During  this  period  the  department  should  be 
aired  out  thoroughly.  In  addition  to  this  rule  the  medical  staff 
should  constantly  urge  the  employees  to  get  out  of  the  plant  at  the 
noon  hour  and  secure  some  healthful,  invigorating  exercise. 

If  a  restaurant  is  maintained  at  the  plant,  it  is  the  duty  of  the 
medical  staff  to  keep  a  close  supervision  over  it.  The  following 
measures  should  be  adopted  in  this  respect: 

1.  Periodical  medical  examination  of  all  employees  in  the  restau- 
rant. Every  employee  handling  or  preparing  the  food  or  working 
in  the  kitchens  should  be  thoroughly  examined  every  three  months  to 
ascertain  if  any  diseased  condition  exists  that  could  contaminate  the 
food  being  served  to  the  employees.  No  one  should  be  allowed  to  go 
to  work  in  the  restaurant  without  first  being  examined. 

In  one  industry,  during  one  year,  where  this  plan  was  followed, 
two  cases  of  tuberculosis,  two  of  active  syphilis,  one  of  diphtheria 
and  one  gonorrheal  case  were  prevented  from  being  employed  in  the 
restaurant.  In  addition  a  young  girl,  a  foreigner,  who  was  to  be 
employed  as  a  dishwasher  was  found  to  be  bodily  filthy.  She  had  not 
bathed  for  seven  months  according  to  her  own  statement.  No, 
she  was  not  rejected,  but  rather  was  given  a  bath  by  the  nurse  and  was 
then  employed  with  the  understanding  that  she  could  hold  her  job 
by  bathing  twice  a  week.  She  reported  once  a  week  to  the  nurse  who 
ascertained  if  she  was  living  up  to  the  contract.  The  contract,  by 
the  way,  was  made  between  the  doctor,  the  nurse  and  the  girl  and 
no  one  else  knew  of  the  condition.  This  girl  is  now  one  of  the  best 
waitresses. 

The  ruling  out  of  these  diseased  conditions  undoubtedly  prevented 
the  spread  of  disease  among  many  employees.  Such  a  system  should 
become  universal  and  should  be  carried  on  by  every  city  health  de- 
partment in  the  land  as  regards  the  public  eating  places. 

A  business  man,  whom  I  told  of  this  condition,  immediatelj^  had 
his  four  servants  at  home  examined  by  his  family  physician,  and  one 
or  them,  the  cook,  was  discovered  to  have  an  active  tuberculosis. 

2.  A  sanitary  inspection  of  the  kitchen  and  dining  rooms,  the 
store  rooms,  pantries,  and  refrigerators  should  be  made  frequently  by 


112  INDUSTRIAL    MEDICINE    AND    SURGERY 

the  medical  staff.  These  inspections  if  backed  up  vigorously  by  the 
management  will  do  more  than  anything  else  to  provide  clean,  sanitary 
conditions  in  the  restaurant.  They  are  essentially  a  part  of  the  health 
supervision  of  the  employees. 

The  following  outline  suggests  the  things  which  should  be  inspected. 

SANITARY  INSPECTION  OF  A  RESTAURANT 

I.  General  Survey : 

(a)  Is  it  clean? 

(b)  Is  it  well  ventilated? 

(c)  Is  it  well  lighted  and  frequently  aired  out? 

(d)  Is  it  smelly? 

(e)  Is  it  located  near  unsanitary  surroundings? 

II.  The  Kitchen : 

(a)  Is  it  clean? 

(b)  Is  it  screened? 

(c)  Are  flies  present. 

(d)  Is  the  food  left  unduly  exposed? 

(e)  Are  the  tables  greasy  or  covered  with  remnants  of  food? 
(/)  Are  the  cracks  in  tables  clean? 

(g)  Is  the  stove  clean? 

(h)  Are  the  ovens  clean? 

(i)  Are  cobwebs  present? 

(j)  Is  the  plumbing  in  good  condition  and  drain  pipes  free? 

(fc)   Is  garbage  left  about  and  exposed? 

(l)  Is  the  refrigerator  clean,  free  of  spoiled  food,  sweet  smelling, 

and  are  the  corners  free  of  grease  and  food  particles?     Is  good 

drainage  from  ice-box  provided? 
(m)  Are  the  store  rooms  clean;  the  shelves  well  arranged;  and 
no  spoiled  food  about? 

III.  The  Dining  Room : 

(a)  Is  it  clean? 

(5)  Is  it  screened? 

(c)  Are  flies  present? 

(d)  Are  the  tables  clean  and  free  of  particles  of  food? 

(e)  Are  the  dishes  clean? 

(/)  Are  cracks  in  tables  free  from  food  particles? 

IV.  Any  Other  Unsanitary  Conditions  Present? 

3.  The  food  should  be  frequently  inspected.  The  milk  and  ice 
cream  should  be  bacteriologically  examined.  Every  effort  should  be 
made  to  see  that  nourishing,  well  prepared  food  is  served. 


FOOD 


113 


In  a  cafeteria  conducted  by  an  industry  the  lunches  ordered  were 
carefully  studied.  This  revealed  that  among  the  girls  and  younger 
employees  especially,  the  average  lunch  consisted  of  ice  cream,  a  dill 
pickle,  a  piece  of  cake  and  some  candy;  or  some  other  equally  un- 
balanced diet.  The  management  was  prevailed  upon  to  serve  only 
nourishing  food.  Suggested  menus  were  displayed  and  every  effort 
made  to  influence  the  employees  to  buy  proper  food.  Some  went  to 
outside  cafes  where  the  pastries  and  pickles  were  served  but  the 
majority  fell  into  line. 


Fig.  20. — A  model  cafeteria  for  employees. 


Where  restaurants  in  the  neighborhood  of  the  plant  are  patronized 
the  plant  physician  can  take  it  upon  himself  to  make  an  unofficial 
inspection  of  these  places.  If  unsanitary  conditions  are  found  or 
questionable  food  is  being  served,  he  can  report  the  place  to  the 
municipal  health  authorities. 

Close  co-operation  should  be  developed  between  the  medical  de- 
partment and  the  city  health  department  as  frequently  you  are 
forced  to  appeal  to  them  on  many  accounts. 

The  Cincinnati  MilHng  Machine  Company  under  the  direction 
of  Dr.  Otto  Geier  has  recently  developed  a  most  efficient  system  for 
feeding  their  employees.  Through  the  courtesy  of  Dr.  Geier  I  am 
permitted  to  publish  pictures  of  this  restaurant  and  of  the  floor  plan- 


114 


INDUSTRIAL   MEDICINE   AND    SURGERY 


FOOD  115 

No  national  health  program  will  ever  be  complete  that  does  not 
include  careful  supervision  of  foodstuffs,  the  places  where  they  are 
prepared  and  served,  the  people  handling  them,  combined  with  an 
educational  campaign  as  to  the  proper  foods  which  should  be  eaten. 
The  physician  in  industry  has  it  within  his  power  to  initiate  this  fea- 
ture of  a  health  program  for  a  limited  number  of  people  at  least. 

Fig.  21. — Dining  room,  floor  plan,  showing  Cafeteria  and  its  relation  to  commissary 
•and  locker  room.  (Cincinnati  Milling  Machine  Co.,  Cincinnati,  Ohio.)  {From 
"Employees  Service  News.") 

Tlie  dining  room  has  a  seating  capacity  of  six  hundred.  The  flow  of  the  employees 
through  the  locker  room  into  the  dining  room  at  the  noon  hour  is  indicated  by  the 
arrows.  The  three  self  service  counters  with  cashiers  at  the  cash  registers,  with  their 
corresponding  checkers,  permit  of  a  very  rapid  movement  into  the  dining  hall.  But 
ten  minutes  is  consumed  in  passing  six  hundred  into  the  dining  room.  The  convenient 
position  of  the  kitchen  reduces  labor  cost.  The  shop  band  plays  in  the  dining  room 
during  the  lunch  period.  The  space  under  the  band  stand  provides  a  place  for  the  re- 
frigerating machinery  which  is  connected  up  with  the  refrigerators  in  the  kitchen  and 
within  the  self  service  counters  space. 

The  self  service  plan  makes  it  possible  for  the  employees  to  have  their  choice  of  two 
or  three  kinds  of  meats,  as  many  vegetables,  salads  and  pastries  as  will  suit  both  their 
appetites  and  their  purses.  It  affords  hot,  well  cooked,  clean  foods  at  a  minimum  cost, 
and  thus  should  add  much  to  the  physical  well-being  of  the  shop  force.  The  average 
check,  in  spite  of  the  high  cost  of  food,  is  twenty  cents. 


CHAPTER  XII 
RECORDS 

In  any  industry  sufficiently  modern  to  recognize  the  value  of  a 
medical  service,  practical,  business-like  methods  prevail — the  same 
must  be  applied  to  the  medical  department.  It  has  been  pointed  out 
in  previous  chapters  that  the  frequent,  periodical  medical  examinatiork 
of  each  employee  would  be  more  ideal,  but  such  a  plan  is  not  feasible. 
More  practical  methods  of  meeting  the  situation  had  to  be  formed. 
Again  it  might  be  more  efficacious  if  the  doctor  spent  more  time 
in  the  routine  medical  examination  of  applicants  but  such  would 
interfere  with  the  real  business  of  the  industry,  which  after  all  is  not 
the  running  of  a  young  hospital. 

Rapid,  efficient  methods  are  demanded  in  all  departments  and 
the  successful  industrial  surgeon  has  met  these  demands.  At  the 
same  time  the  high  standards  of  professional  work  have  been 
maintained. 

Records  setting  forth  the  history  of  the  patient,  the  diagnosis, 
the  character  of  the  treatment  given  and  other  necessary  data  are 
now  recognized  as  indispensable  to  the  really  scientific  physician. 
The  history  sheets  and  records  usually  employed,  however,  are  entirely 
too  voluminous  for  industrial  practices.  Therefore  the  records  of  the 
various  medical  departments  in  industries  have  been  boiled  down 
until  we  now  have  several  very  efficient  systems  of  record  keeping. 
Practically  all  such  records  show  only  positive  statements  or  findings. 
Thus  if  the  history  is  negative  the  space  for  history  is  left  blank. 
If  venereal  diseases  are  denied  nothing  is  mentioned  about  them.  On 
the  other  hand  it  is  much  wiser  to  record  either  positive  or  negative 
findings  wherever  the  question  of  compensation  may  be  involved. 
For  example  an  applicant  is  found  to  have  no  hernia  at  his  examination 
for  employment.     The  record  should  show  ''no  hernia. " 

In  the  following  pages  I  have  presented  examples  of  record  cards 
used  in  my  industrial  clinic  wliich  have  been  adopted  after  several 
years  of  experience.  While  this  may  not  represent  the  best  system 
yet  it  shows  the  number  of  different  records  it  is  necessary  to  keep  and 
the  manner  of  combining  them  into  one  record. 

FILING 

Formerly  separate  cards  were  kept  for  medical,  surgical,  social 
and  dental  cases.  Now  all  of  these  are  combined  in  one  record  called 
Doctor's  Office  Record.  This  record  is  kept  in  a  folder  and  filed  ac- 
cording to  the  cross-index  system  (according  to  name  and  number). 

116 


RECORDS 


117 


In  order  to  quickly  discern  the  medical,  surgical  or  dental  record  on 
a  case,  the  surgical  record  and  all  pertaining  to  it,  namely,  nurse's 
calls,  laboratory  or  rc-ray  reports  are  typed  in  red;  the  medical  record 
in  black  and  the  dental  in  purple. 


INFORMATION  RECORD 


Name- 


Hosp.  No.. 

Serial  No.. 

Married    I 
Single       i 


nil    S 

Dale 

Address 

Dept. 

Telephone 

Occupation 

Date  Emp.  or  Rein.  * 

Dale  Resigned 

Caase 

Physical  Examination 

(History  of  Diseases,  Acddents  or  Operations.) 


Family 


Exam,  for  Emp. 

Temp. 

Pulse 

Height 

Weight 

Eye  Test 

Urinalysis:  Albumin 

Sugar 

Micro. 

R 

Result  of  Exam. 

L 

Both 

Doctor's  Recommendations 


He.examinations 


Fig.  22. — Information  record  for  applicants  for  work.  This  is  made  out  in  dupli- 
cate by  the  employment  department  and  is  sent  with  the  applicant  when  he  comes 
to  the  doctor's  office  for  physical  examination.  The  nurse  takes  the  medical  personal 
history  of  applicant,  also  temperature,  pulse,  weight,  height,  eye  test  and  urinalysis. 
The  applicant  is  then  sent  in  to  the  doctor,  who  examines  him.  If  physical  defects 
are  found  which  might  interfere  with  his  work  at  present,  applicant  is  asked  to  report 
for  re-examination.  After  being  examined,  he  takes  both  original  and  duplicate  to 
employment  department.  If  he  is  employed,  the  employment  department  notes  the 
department  to  which  he  is  assigned,  also  serial  number  and  returns  original  copj^  with 
this  information  to  doctor's  office.  In  case  of  handicapped  persons  who  are  employed 
their  job  is  selected  after  a  conference  between  the  employment  manager  and  the  doctor. 


118  INDUSTRIAL   MEDICINE    AND    SURGERY 


DOCTOR'S  OFHCE  PASS       M      18351  Date. 

Name Oept. 

Serial 
Address Number 


O.K.. 


I  Duplicate  and  Send  Both  Copies  to  Doctor'*  Office. 


Fig.  23. — Doctor's  office  pass.  This  pass  is  issued  in  duplicate  to  the  employee 
who  wishes  to  go  or  is  called  to  report  at  the  doctor's  office.  He  gives  it  to  the  record 
clerk  at  the  door,  she  numbers  and  stamps  time  in  on  it,  then  gives  the  original  to  the 
file  clerk  to  look  up  employee's  record.  When  employee  is  ready  to  leave  the  depart- 
ment, the  doctor  or  nurse  who  last  cared  for  him,  returns  pass  and  he  again  presents  it  to 
the  record  clerk  at  the  door.  She  looks  up  duplicate,  stamps  both  with  time  out  and 
gives  duplicate  to  the  employee  to  give  to  his  manager  and  retains  the  original  at  this 
office. 


RECORDS 


119 


n^tlrmpfeyrf    10/16/1916.        DOCXOH'3  OFPICR  BBCOBD 
6.  M.  B.  A. '■ 

Name         Casey,    John. Dept     187        Hosp.  No.    XXXX. 


DATE 

'Tl.f 

Pnji 

,.,. 

REMARKS  AND  SICNATUIIE  OF  PHYSICIAN  OR  NURSE 

"!.t,v' 

umiin. 

V^'r 

1/3/1 

it 

n 

131 

IndlKesUfn.      SeldllU.   Daot.       C.M.E 

1/18/ 

.0 

Abraded  left  thumb  on  broken  china.   Piece 

of  chlnet  removed.  D.D.  To  report  In  A.M. 

DR .  VA  RMRTiRR  • 

i/ia/ 

A 

p,p.    niof-h- 

i^/ 

20/16: 

00 

66 

Headache.   Aches  all  over.   Influenza. 

10. 3C 

DR.  ELLIS. 

12 

'22/lC 

&9. 

6 

Reporting.   In  no  condition  to  return  to  work. 

■ 

Horn*,  again.                  DR. ELLIS 

12 

27/16 

Nurse's  call  A.V.C.   Absent  since  12/20/16. 

.- 

. 

Reported  12/22/16, but  Was  given  pass  home 
aRain.   Has  grippe.   Has  had  no  doctor,  but 

la  using  home  remedies.   Is  up  and  ground, but 
very  weak  and  rundown. Temp. 96.2  Return  indefln 

Ito. 

1 

12/17 

n* 

12/ 
Influenza.   Examination  neRatlva. 

22/ H^ 
2  f,i 

faA.I 

[17  da 

tlnnt. 

1-^0- 

17 

All  t.BBth  pyorrhelc.   Referrad  to  family  D.D.S 

advleing  cleanln£  and  1  filling.   Beoall 

?-!>fi^^7  .                  5r.,  mobtgoheby. 

Dmry*  . 

!>-?R- 

17 

Raportlnj.   i'roper  prophylaxla  adminlsterad  ty 

family  D.D.S.   Euaceptiblllty  to  focal  infect- 
ion nflglegitle.                 DR.  MOHTGOMiRY. 

3 

22/17 

Resigned. 

2  '10/ie 

Reinstated. 

1 

4  '29/18 

6.30  A.M.  Tlhlle  at  work  on  4/27/ifl  panhlne 

hardware, pat lent  punctured  right  index  finger 

to  It  and  did  not  us©  iodine.  Mo  witness. 

Reported,  here  4/29/18  8.30  A.M.  Finger  swollen 

1. 

ana  painrui.  Temp. 100.4.  Sean  by  Dr. Pox  and 

Advised  because  of  lyBphangltls.At  1  P.M. 

tampni.atnT>n  JOO.fi.  <»Ant  f,n   WflphlnfT^^n  Plvd  HOBl 

for  continuous  hot  dressings. 

. 

/3/18 

Reporting.  Left  hospital  this  A.M. 

/6/18 

Returned  to  work.       OB.POX'. 

Fig.  24. — Doctor's  ofl&ce  record.  This  is  made  out  either  the  first  time  the  em- 
ployee comes  to  the  doctor's  office  for  examination  or  treatment  or  when  a  nurse's 
call  is  made  at  an  employee's  home.  All  subsequent  information  and  treatment  of 
whatever  nature  is  kept  on  this  record.  The  medical  record  is  written  in  black;  the 
accident  record  in  red  and  the  dental  record  in  purple  thus  facilitating  the  reading 
of  the  record. 


120 


INDUSTRIAL    MEDICINE    AND    SURGERY 


EMPLOYE'S  GENERAL  PASS 


This  pass  to  be  o&ed  £oix^  ironk  one  department  to  another*  one  building  to  anotherp 
or  Trhen  leaving  plant  for  any  purpose  whatsoever. 


To  Usher: 

Ffom  Dppt 

fn 

Reason                . ..     _.  .... 

On  the  above   Udcs  dcelenate  the  department  and   bulldlnff  to   which   tbo  employe  is   sent      If   the  cmploro   is   Jcavlnu 
tbe  prcrolfles,   stale   If  for  oerbonal   reason   or  on  house  business. 

TUIb  paes  win  serre  as   an  ItlentiflcaUon  card   and  when   going  out  of  or  into  dlfTerent  buUdlngB  must  be  showti 


tZw  premises  not  to  return  for  the  day,  in  which  caee  it  will  be  taken 


the  i)erBon    O.  K." 


except  where  em{>loyo   loaves 


Fig.   25. — Employee's   pass   home.       This   is   issued   by   the   doctor's   office   when   an 
employee  is  sent  home  on  account  of  illness. 


EMPLOYES'  RETURN  TO  WORK  PASS 


Date  employed. 


_Date 


Member  nf  S.   M.   B.  A._ 


Name_ 


Dept. 


Returned  to  work  today.      Absent- 
account  of : 


_days  on 


Should  report  to 


Doctor's  office- 


Signed- 


Fig.  26. — Return  to  work  pass.     This  is  issued  by  the  doctor's  office  when  employee 
is  able  to  return  to  work  after  absence  on  account  of  illness. 


RECORDS  121 


REPORT  OF  ACCIDENT 


No.- 


INSTRUCTIONS:— Accidents,  However  Slight,  Must  Be  Reported  In  Full 


Date 191- 


ALL  OF  THESE  16  QUESTIONS  WILL  BE  FILLED  OUT  IN  THE  DOCTOR'S  OFFICE 

1.     Name ^ 2.     Address 


3.     Department 4      Age Years Mos.     5.      Occupation- 

6.     Nature  and  Extent  of  Injury 


7-     Description  of  Accident  by  Injured  Person  (Give  full  details). 


8.     Statement  of  Witness  or  Other  Person  Familiar  with  Accident- 


9.  Name  and  Location  of  Machine,  Appliance  or  Thing  Causing  Accident- 

10.  Wtere  Taken  After  Accident? 

11.  Name  of  Attending  Physician 

12.  Probable  Length  of  Disability 


13.     Date  of  Accident Hour 14.     Date  Reported  to  Doctor's  OfEc 

15.     Remarks 


16.    If  sent  outside  of  Doctor's  Office  for  treatment,  state  where  sent,  why,  and  when  sent  (date  and  hour) 


In  case  of  operation  or  treatment  of  any  kind,  outside  of  Doctor's  Office,  full  details  must  be  given  in  space  pro» 
vided  on  Final  Accident  Report. 


Signed- 


FiG.  27. — Report  of  accident.  This  record  is  made  out  in  quadruplicate  on  all 
accident  cases  where  time  is  lost.  One  copy  is  retained  in  employee's  record,  one 
is  sent  to  the  safety  engineer,  one  is  sent  to  the  manager  and  the  other  is  sent  to  the 
payroll  department. 


122 


INDUSTRIAL   MEDICINE    AND    SURGERY 


QUESTIONS  17  TO  32  TO  BE  FILLED  OUT  IN  THE  DEPARTMENT 


17.  Length  of  Service  of  the  Employe. 

18.  Has  He  a  Wife  or  Children? 


19.  How  Long  Engaged  on  This  Work? 

20.  Was  Injured  Person  Familiar  or  Not  With  the  Work  Engaged  in, 
or  With  the  Machinery  Operated  at  the  Time  of  the  Accident?- 

21.  Instructed  as  to  Its  Hazards? 


22.  Has  He  Done  Similar  Work  Prior  to  This  Employment? 

23.  Was  Accident  Due  to  Want  of  Care  on  the  Part  of  Injured  Person?- 

24.  Was  Accident  Due  to  Negligence  on  the  Part  of  Any  Person? 

25.  If  So,  How? 


26.  Who  Was  in  Charge  of  the  Work  Where  Accident  Occurred?- 

27.  Give  Names  and  Addresses  of  Witnesses 


28.  Is  Injured  Person  a  Mer^ber  of  the  S  "M    B.  A.  ? 

29.  Should  S..  R  &  Co   Pay  Salary  Durmg  Disability' 

30.  Serial  No 

32.  Remarks 


31.     Time  Card  No.. 


Signed- 


Date- 


Manager  Dcpt.. 


A.  E.  &  C.  CHECKS  ISSUft)  FOR  TIME  LOST 

Chech  Isftued 

For  Week 
Ending 

Days  Paid 
For 

Amonnt 

Check  Issued 

For  Week 
Ending 

DayaPaM 
For 

AmoDDt 

Check  Issued 

For  Week 
EadlDp 

DaysPatd 
For 

Amount 

Fig.  28. — Back  of  accident  report  to  be  filled  out  in  the  department. 


RECORDS 


123 


FINAL  ACCIDENT  REPORT. 


SUPPLEMENTARY  TO  ORIGINAL  REPORT. 


3.     Department- 


.  Emp.  No 


5.     Nature  of  Injury  . 


4.      Occupatio 


6.     Dateof  Accidenl- 


7.  Date  of  Returning  to  Work — 

8.  Partial  or  Complete  Recovery - 


9.     Amount  ol  DisabiLty  (time).     Fr< 

10.  Name  of  Attending  Physician 

11.  Remarks 


12.     If  taken  to  an  outside  hospital,  fill  out  the  following; 

Name  of  Hospital  

Date 

Nature  of  Treatment  or  Operation 


Attending  Physician  or  Surgeon- 
Length  of  Time  in   Hospital 


13.     If  given  treatment  outside  of  Doctor's  Office  or  outside  hospital,  fill  out  the  following: 
■Where  Treated . 


Nature  of  Treatment- 


Name  of  Physi 


Signed- 


FiG.  29. — Final  accident  report.  This  report  is  made  out  in  quadruplicate  on  all 
accident  cases  where  time  is  lost,  when  an  employee  returns  to  work.  One  copy  is 
retained  in  employee's  record,  one  sent  to  the  safety  engineer,  one  sent  to  the  manager 
and  the  other  is  sent  to  the  payroll  department. 


124  INDUSTRIAL    MEDICINE    AND    SURGERY 


Date 

RLPORT  OF  NUR5L'5  CALL      „       .     , 

Kequesfed  by_ 
Name Dept. 


_5.  M.  B.  A._ 


Length  of  Service 1st  Day  Absent. 


Dr Address_ 


Instructive  . 
.Nursing 


Remarks  . 


F«9L9  To  be  made  out  in  TRIPLICATL. 

Fig.  30. — Request  for  nurse's  call.  This  is  made  out  in  triplicate  by  departments 
and  sent  to  the  doctor's  office  when  requesting  a  nurse's  call.  One  copy  is  retained 
in  the  doctor's  office,  one  is  sent  to  the  department  and  the  third  is  sent  to  the  welfare 
department.  The  one  retained  by  the  doctor's  office  is  filed  according  to  date  and  kept 
for  one  month  or  until  the  monthly  report  is  made  out.  If  the  doctors  or  nurses  wish 
call  or  revisit  made  on  an  employee,  they  also  fill  out  one  of  these  blanks,  dating  it 
for  the  day  they  wish  call  to  be  made.  It  is  then  put  in  file  for  that  day  and  is  auto- 
matically handled  at  that  time. 


CHAPTER  XIII 
INDUSTRIAL  HEALTH  SERVICE 

A  RESUME  OF  ITS  GROWTH 

Hygiene,  which  is  the  science  of  health  preservation,  and  deals 
with  all  the  laws  of  sanitation,  has  developed  a  specific  significance 
when  applied  to  Industry.  It  includes  plant  sanitation,  prevention  of 
occupational  diseases  and  most  of  the  measures  adopted  for  the  super- 
vision of  the  health  of  employees. 

From  the  employer's  standpoint  industrial  hy giene  is  now  lecognized 
as  the  cornerstone  of  maximum  production.  From  the  standpoint  of 
the  medical  man  it  is  the  cornerstone  of  preventive  medicine. 

Industrial  Hygiene,  however,  does  not  include  the  entire  field  of 
Industrial  Medicine  and  Surgery — a  mistake  which  apparently  has 
been  made  by  some  workers  in  this  field.  The  all-round  Industrial 
Surgeon  must  have  a  clear  understanding  of  these  laws  of  industrial 
sanitation  but  he  must  also  be  a  competent  diagnostician  and  capable 
of  treating  disease  and  injuries. 

This  form  of  public  health  service  was  rarely  mentioned  prior  to 
fifteen  years  ago,  but  to-day  it  is  receiving  the  attention  of  engineers, 
physicians  and  employers  in  general.  Medical  schools  and  engineering 
schools  are  teaching  their  students  various  phases  of  Industrial  Hygi- 
ene. State  Legislatures  are  enacting  new  laws  to  better  the  sanitary 
conditions  of  workmen.  In  fact,  few  subjects  have  received  such 
widespread  attention  or  have  reacted  for  greater  good  to  the  nation 
in  so  short  a  time. 

In  1911  the  author  published  the  following  statements  in  a  booklet 
on  Medical  Work  and  Sanitation  in  Industry: 

"Industrial  sanitation  is  practically  a  new  subject.  While  it  is 
years  behind  other  forms  of  sanitation,  such  as  the  work  of  our 
municipal  and  state  boards  of  health,  the  improvement  of  conditions 
in  state  prisons  and  asylums,  and  the  United  States  Government  meth- 
ods for  the  preservation  of  health  among  our  soldiers  and  sailors,  yet, 
in  this  country,  during  the  last  decade,  some  notable  advances  have 
been  made  tending  to  vastly  improve  the  conditionsof  the  working  men 
and  women.  Chief  among  these  has  been  the  creation  of  departments 
of  Industry  and  Labor  in  many  states  of  the  Union.  Through  the 
work  of  these  departments  child  labor  has  diminished,  shorter  hours 
(especially  for  women  and  children)  have  been  obtained,  women  are 

125 


126  INDUSTRIAL   MEDICINE    AND    SURGERY 

allowed  to  sit  while  at  work  and  are  surrounded  by  healthier  and  less 
demoralizing  conditions,  overcrowding  of  workshops  has  been  greatly 
reduced,  and  employees  are  more  and  more  protected  from  dangerous 
machinery  and  injurious  gases  and  dusts.  But,  the  advancement 
thus  far  along  these  lines  is  only  a  very  small  beginning,  and  a  careful 
study  of  our  various  state  labor  laws  reveals  the  fact  that  until  these 
are  made  more  stringent,  very  little  can  be  accomplished  for  the  bet- 
terment of  health  in  our  industries. 

"The  report  of  the  Department  of  Commerce  and  Labor  for  1909 
and  the  various  state  labor  laws  show  that  only  twenty-one  states  have 
a  section  bearing  directly  upon  the  subject  of  factory  and  workshop 
sanitation.  Alabama,  Illinois,  Massachusetts,  Minnesota,  Ohio,  Ore- 
gon, Tennessee  and  West  Virginia  state  that  all  workshops  must  have 
'proper  ventilation  and  proper  sanitary  conditions,'  but  none  of  these 
makes  specific  recommendations  as  to  what  constitutes  'proper.'  The 
standard  for  these  conditions  is  evidently  left  to  the  judgment  of  the 
State  Factory  Inspector — which  is  not  always  a  good  plan.  The  laws 
of  Indiana,  Maryland,  New  Jersey,  New  York,  Pennsylvania  and  Wis- 
consin are  somewhat  better,  because  these  states  require  that  every 
employee  within  an  enclosure  must  have  a  certain  amount  of  air 
space,  varying  from  250  to  400  cubic  feet  per  person.  These  states 
are  also  slightly  more  specific  in  their  requirements  for  proper 
sanitary  conditions.  Illinois  and  New  York  have  stronger  laws  than 
the  few  other  states  that  mention  it,  dealing  with  the  restriction  of 
the  sale  of  articles  manufactured  by  diseased  employees  or  made  in 
unhealthy  surroundings.  Practically  all  of  these  states  require  that 
fans,  blowers  and  suction  pipes  shall  be  installed  in  workshops  where 
injurious  gases  or  dust  exist,  to  facilitate  the  removal  of  the  same. 
Missouri  and  New  Jersey  require  the  painting  or  whitewashing  of  the 
interior  of  all  workshops  at  least  once  a  year.  Missouri  has  a  law 
against  overcrowding  of  factories,  which  can  be  enforced  if  a  certificate 
is  obtained  from  any  reputable  physician  that  said  factory  is  crowded 
to  the  extent  that  it  is  unhealthful. 

"Massachusetts  alone  requires  the  placing  of  cuspidors  in  all 
buildings  where  people  are  employed.  But  neither  Massachusetts  nor 
any  other  state  legally  stipulates  how  these  cuspidors  shall  be  cleaned 
or  handled.  It  is,  indeed,  paradoxical  that  we  have  laws  prohibiting 
spitting  anywhere  but  in  cuspidors,  and  yet  there  are  no  laws  designat- 
ing how  the  contents  of  the  same  shall  be  disposed  of.  In  most  cases 
disposal  is  left  to  the  whims  of  the  porter  in  charge.  The  fact  that  the 
death  rate  from  consumption  is  higher  among  porters  than  among  any 
other  class  of  workers  points  to  the  highly  infectious  nature  of  the 
contents  of  these  cuspidors.  Not  alone  the  porters,  but  the  whole 
community  is  exposed  by  the  careless  handling  of  these  germ  incu- 


INDUSTRIAL    HEALTH    SERVICE  127 

bators  where  the  flies  dehght  to  feed.  There  is  no  state  law  in  the 
country  prohibiting  consumptives  from  working  in  intimate  contact 
with  other  employees,  and  only  a  few  states  specify  that  consumptives 
shall  not  be  employed  in  bakeries  or  other  places  where  food  products 
are  prepared.  Even  these  do  not  provide  for  regular  inspection 
of  such  employees  by  a  physician  in  order  to  rule  out  the  tuberculous. 

"This  short  resume  of  the  various  state  labor  laws  in  their  relation 
to  sanitation  will  certainly  impress  the  layman,  who  is  especially  in- 
terested, as  well  as  any  medical  man,  with  their  great  lack  of  preventive 
legislation,  which,  if  enacted  and  enforced,  would  greatly  reduce  the 
death  rate  among  the  wage  earners,  and  at  the  same  time  improve  the 
hygienic  and  economic  conditions  of  every  community." 

Since  the  above  was  published  almost  every  state  in  the  Union  has 
enacted  laws  seeking  to  improve  the  working  conditions  of  employees. 
Thirty-seven  of  our  states  now  have  laws  on  Employees  Compensa- 
tion. Recently  some  of  these  states  have  included  occupational  dis- 
eases under  the  causes  for  compensation.  To-day  at  least  four  of  the 
states  are  considering  laws  for  sickness  insurance  for  workmen. 

All  of  these  laws,  enacted  for  the  benefit  of  employees,  have 
improved  industrial  health  conditions  to  a  great  extent.  Yet,  we  can 
repeat  our  statement  made  in  1911,  that  a  resume  of  the  laws  must 
impress  one  with  the  lack  of  preventive  legislation,  which  if  enacted 
and  enforced,  would  greatly  reduce  the  death  rate  among  wage  earners. 

If  the  legislative  advancement  along  these  lines  has  been  rather  slow, 
the  voluntary  advancement  of  industrial  hygiene  by  many  of  our  large 
concerns,  by  national  organizations  and  by  a  few  state  departments  of 
Industry  and  Labor  has  been  very  rapid. 

Prior  to  1909  a  few  state  factory  inspectors  and  a  few  other  indi- 
viduals had  called  the  nation's  attention  to  the  wastage  of  human  Ufe 
by  some  of  the  more  flagrant  unsanitary  conditions  in  industry. 
About  this  date  there  seemed  to  be  a  great  incentive  given  to  the 
subject  by  the  writings  of  a  number  of  physicians  connected  with 
industrial  concerns. 

The  studies  of  Dr.  Thomas  Crowder  on  ventilation,  of  Dr.  Alice 
Hamilton  on  lead  poisoning,  of  Dr.  J.  W.  Schereschewsky,  and  of  Dr. 
George  Price  on  health  conditions  among  garment  workers,  and  of  men 
like  Dr.  E.  R.  Hayhurst  and  Dr.  Francis  Patterson  working  in  connec- 
tion with  the  departments  of  Industry  and  Labor  of  the  states  of  Ohio 
and  Pennsylvania  respectively,  stand  out  as  milestones  in  the  advance- 
ment of  Industrial  Health  in  this  country. 

Extending  inspection  to  the  employees  themselves,  by  physical 
examinations,  as  well  as  the  inspections  of  their  working  places,  was  one 
of  the  greatest  advances  ever  made  in  health  supervision  in  this  country. 
In  1906  Dr.  Frank  Fulton,  in  Providence,  R.  I.,  examined  a  number  of 


128  INDUSTRIAL    MEDICINE    AND    SURGERY 

employees  free  of  charge  for  the  purpose  of  discovering  tuberculous 
workers.  This  is  one  of  the  first  examples  recorded  of  a  careful 
effort  at  supervision  of  the  health  of  workmen.  In  1909  Mock  started 
the  examination  of  employees  in  the  concern  of  Sears,  Roebuck  & 
Company,  of  Chicago,  for  the  purpose  of  discovering  the  tuberculous. 
It  soon  became  evident  that  such  a  procedure  revealed  many  other 
diseases,  which,  taken  in  their  incipiency,  could  be  checked.  This 
fact,  because  of  its  economic  basis,  became  one  of  the  strongest 
arguments  in  favor  of  the  physical  examination  of  employees.  Similar 
reports  setting  forth  the  benefits  of  this  practice  were  made  during  the 
next  few  years  by  Dr.  Irving  Clark  of  the  Norton  Grinding  Company, 
Worcester,  Massachusetts,  by  Dr.  Otto  Geier  of  the  Cincinnati 
Milling  Machine  Company,  by  Dr.  Wilbur  Post,  of  the  Peoples  Gas  Co., 
Chicago,  by  Dr.  C.  G.  Farnum  of  the  Avery  Company,  Peoria,  Ill- 
inois, by  Dr.  S.  M.  McCurdy,  of  the  Youngstown  Sheet  and  Tube 
Company,  by  W.G.  Hudson,  of  the  Du  Pont  Company,  and  other  work- 
ers in  this  field.  By  1914  physical  examinations  of  employees  was  a 
fixture  in  many  industries. 

The  Committee  on  Factories  of  the  Chicago  Tuberculosis  Institute, 
composed  of  Drs.  James  Britton,  Theodore  Sachs  and  Henry  Faville, 
was  instrumental  in  extending  this  system  to  a  number  of  the  other 
industries  of  Chicago.  Their  report  on  this  work,  presented  before  the 
National  Tuberculosis  Association  in  1914,  gave  a  marked  impetus  to 
this  branch  of  Industrial  Hygiene  throughout  the  country.  Since 
then  the  National  Tuberculosis  Association  has  been  a  stanch  advocate 
of  this  form  of  medical  work. 

With  the  formation  of  the  National  Safety  Council  such  physicians 
as  Geier,  Patterson,  A.  M.  Harvey,  Farnum,  Irving  Clark,  Mock, 
McCurdy,  C.  A.  Lauffer,  L.  A.  Shoudy  and  others,  pointed  out  the  need  of 
improving  the  hygienic  conditions  of  the  workmen  as  a  definite  part 
of  any  accident  prevention  program.  As  a  result,  this  great  organiza- 
tion formed  its  Health  Service  Section  in  1914,  which  has  been  instru- 
mental in  improving  sanitation  in  so  many  of  our  large  industrial 
concerns. 

In  the  American  Public  Health  Association  Drs.  W.  A.  Evans, 
E.  T.  Fisk,  Alice  Hamilton  and  others  were  among  the  first  to  recognize 
the  influence  of  this  form  of  public  health  work,  and  with  some  50 
other  physicians  formed  the  Section  of  Industrial  Hygiene  in  that 
organization  during  the  fall  of  1914. 

For  years  the  American  Medical  Association  had  frowned  on  the 
contract  practices  and  other  types  of  work  of  the  company  surgeon. 
The  standard  of  this  work  in  many  instances  had  been  far  below  par. 
But  public  recognition  of  this  new  specialty  of  industrial  medicine  was 
given  in  1915  by  this  association.     In  the  annual  meeting  of  that  year 


INDUSTRIAL    HEALTH    SERVICE  129 

the  Preventive  Medical  Section  of  the  American  Medical  Association, 
Dr.  Otto  Geier,  Chairman,  had  a  symposium  on  industrial  Hygiene. 
Since  then  industrial  medicine  and  surgery  has  had  a  place  on  every 
annual  program  of  that  section.  In  addition,  this  year  the  Orthopedic 
section  of  the  American  Medical  Association  had  a  symposium  on 
industrial  surgery.  The  recognition  of  this  work  by  the  leading  mem- 
bers of  our  profession  testifies  to  the  higher  professional  standard  which 
it  has  attained. 

In  the  East,  a  number  of  physicians  in  1914  formed  the  Conference 
Board  of  Industrial  Physicians,  under  the  secretaryship  of  Magnus 
Alexander.  Many  of  the  leaders  in  industrial  medicine  and  surgery 
are  numbered  among  its  members.  Some  of  the  greatest  contributions 
to  industrial  hygiene  have  been  made  by  this  group.  In  the  West,  such 
men  as  Dr.  R.  W.  Corwin,  of  Colorado,  Drs.  Tucker,  Philip  King 
Brown  and  Robert  T.  Legge,  of  California,  Dr.  J.  R.  Yocom,  of 
Washington,  and  others,  have  been  responsible  for  improving  condi- 
tions in  the  mining  and  lumbering  industries. 

Recognizing  that  the  public  health  of  the  nation  was  being  influ- 
enced to  a  very  marked  degree  by  these  various  efforts  of  local  and 
national  organizations,  the  U.  S.  Public  Health  Service  formed  its  divi- 
sion of  industrial  sanitation.  With  such  men  as  Schereschewsky,  C.  F. 
Rucker,  B.  S.  Warren  and  A.  J.  Lanza  in  the  Public  Health  Service, 
and  such  consultants  as  David  Edsall,  Price,  Oilman  Thompson,  A.  S. 
Stengel,  C.  D.  Selby,  and  others,  great  progress  has  been  made  during 
the  last  five  years  in  improving  health  conditions  among  employees 
engaged  in  certain  industrial  lines  where  the  health  hazards  have  been 
excessive. 

Likewise,  the  U.  S.  Department  of  Labor  has  rendered  most  valuable 
servicetothecountiy  through  the  work  of  Drs.  Alice  Hamilton,  Royal 
Meeker,  L.  P.  Cheney,  and  others.  These  workers  and  their  assistants 
have  made  exhaustive  studies  along  various  lines  of  industrial  sanita- 
tion. Their  work  on  occupational  diseases,  accident  hazards,  fatigue, 
ventilation,  lighting  and  numerous  other  subjects,  has  formed  a  basis 
for  correcting  faulty  conditions  in  many  kinds  of  industry. 

The  Bureau  of  Mines  has  been  engaged  in  a  similar  service  in  the 
mining  industries  of  the  country.  These  efforts  of  the  National  Gov- 
ernment to  improve  the  hygienic  conditions  of  the  employees  of  the 
nation's  industries  are  most  praiseworthy.  They  mark  the  beginning 
of  what  must  finally  come  to  pass — a  centralized  supervision  of 
health  conditions  throughout  the  country,  not  only  among  industrial 
employees  but  in  all  walks  of  life. 

It  is  to  be  deplored  that  several  Federal  departments  are  engaged 
in  this  work,  as  at  present.  The  desire  to  justify  appropriations,  to 
secure  credit  for  doing  a  piece  of  work,  and  certain  interdepartmental 


130  INDUSTRIAL   MEDICINE    AND    SURGERY 

jealousies  which  prevent  proper  co-operation  between  departments, 
all  tend  to  duplication  of  effort  and  retardation  of  results. 

There  is  no  doubt  that  certain  angles  of  this  work  has  to  do 
directly  with  the  question  of  labor.  But  the  chief  problems  of  indus- 
trial hygiene  are  primarily  health  problems  and  should  be  centralized 
under  that  federal  agency  which  is  responsible  for  the  public  health 
of  the  nation. 

In  1916,  recognizing  the  great  need  of  uniting  to  secure  the  greatest 
advancement  in  these  health  problems  in  industry,  the  physicians 
and  surgeons  of  the  country,  engaged  in  industrial  medicine  and  sur- 
gery, organized  the  American  Association  of  Industrial  Physicians 
and  Surgeons.  The  men,  who  during  the  preceding  eight  or  ten  years, 
had  been  striving  alone  or  in  subsections  of  other  organizations,  now 
met  for  the  first  time  as  a  united  group  with  a  common  purpose.  The 
combined  efforts  of  this  association  has  undoubtedly  done  more  to 
raise  the  standards  of  the  physician  engaged  in  industrial  practice, 
and  to  increase  the  benefits  from  this  work  to  both  employees  and 
employers,  than  any  other  one  agency  which  has  entered  this  field. 

During  the  last  five  years  medical  schools  have  recognized  the 
great  opportunity  for  service  offered  to  physicians  in  the  field  of  in- 
dustrial medicine  and  surgery.  Doctor  Legge,  at  the  University  of 
California,  started  a  course  on  Industrial  Hygiene  which  has  become 
very  popular  with  all  the  students.  Hayhurst  instituted  a  similar  course 
in  the  University  of  Ohio.  Stengel  at  the  University  of  Pennsylva- 
nia, and  Thompson  at  Cornell,  introduced  the  subject  of  occupational 
diseases  in  the  curriculum  of  those  schools.  Harvard,  co-operating 
with  the  Massachusetts  General  Hospital,  has  held  clinics  on  occupa- 
tional diseases  for  several  years.  Mock  at  Rush  Medical  College, 
some  three  years  ago,  started  a  night  clinic  on  industrial  medicine 
and  surgery.  It  has  had  the  strong  support  of  such  men  as  Billings, 
Herrick,  Dodson,  Ellis  and  others,  and  is  now  recognized  as  one  of  the 
great  sociologic  movements  of  Chicago.  This  course  affords  the  stu- 
dents a  very  broad  training  in  every  phase  of  work  encountered  by  the 
physician  in  industrial  practice.  No  one  effort  put  forth  by  medical 
schools  will  yield  so  great  a  return  in  benefits  to  the  nation's  health  as 
these  courses  on  industrial  medicine. 

A  great  many  other  men,  both  physicians  and  laymen,  have  had 
an  important  part  in  developing  this  great  public  health  movement. 
Through  their  efforts  industrial  medicine  and  hygiene  have  become 
most  potent  factors  in  the  Industrial  life  of  our  nation.  Never  again 
will  we  return  to  those  dark  ages  when  the  human  machine  was  driven 
to  the  limit  without  lubrication  or  repair  and  simply  "scrapped" 
when  disease,  often  the  direct  result  of  the  occupation,  robbed  it  of 
further  usefulness. 


INDUSTRIAL   HEALTH    SERVICE  131 

The  physicians  and  other  workers  in  industrial  hygiene  cannot 
cla-im  all  the  credit  for  the  developments  that  have  taken  place  in  this 
field.  Some  of  our  large  corporations,  without  the  help  or  advice  of 
medical  men,  have  voluntarily  started  improvements  in  the  working 
conditions  of  their  employees.  The  work  of  the  National  Cash  Regis- 
ter Company,  at  Dayton,  Ohio,  will  always  stand  out  in  the  industrial 
history  of  our  country  as  one  of  the  pioneer  efforts  to  improve  condi- 
tions for  the  comfort  and  welfare  of  the  employees.  There  may  be 
many  criticisms  of  the  system  adopted  by  that  concern,  but  neverthe- 
less its  example  and  influence  was  a  great  stimulus  to  other  em- 
ployers to  take  a  more  humane  attitude  toward  their  people. 

In  more  recent  years  the  Ford  Motor  Company  has  adopted  a 
broad  economic  and  sociologic  policy  toward  their  employees  which 
has  for  its  very  foundation  most  of  the  principles  of  industrial  hygiene. 
They  have  found  it  necessary  to  form  the  closest  co-operation  between 
their  sociologic  department  and  their  medical  department.  In  fact, 
in  very  few  concerns  is  the  medico-sociologic  aspects  of  this  work 
in  industry  more  clearly  demonstrated. 

The  housing  experiments  of  the  United  States  Steel  Corporation 
are  well  known,  and  mark  a  decided  advance  in  industrial  hygiene. 
Many  other  concerns  in  this  country  have  recognized  the  relation- 
ship between  improved  home  conditions,  better  health  and  increased 
production. 

As  a  result  of  these  combined  efforts  of  individuals,  organizations, 
and  certain  employers  on  the  one  hand,  and  of  the  various  state  and 
federal  agencies  on  the  other,  we  are  able  to  point  to  approximately 
8,000,000  of  the  workers  of  the  nation  who  are  receiving  the  benefits 
of  this  enlightened  era  in  industry  to  a  more  or  less  degree.  There 
still  remain  about  30,000,000  of  our  people  who  are  responsible  for  pro- 
duction of  some  type  in  this  country  who  are  not  receiving  any  kind  of 
health  supervision.  Many  of  these  are  working  under  intolerable 
conditions.  The  amount  of  child  labor  still  in  use  is  unbelievable. 
The  lack  of  protection  against  the  commonest  forms  of  occupational 
diseases  is  appalling. 

Even  in  many  of  those  concerns  where  maximum  production  is  so 
essential  at  this  time  for  the  winning  of  the  War  we  find  inadequate 
housing  conditions,  unsanitary  factory  conditions,  prevalence  of  occu- 
pational diseases,  and  a  high  accident  rate  due  to  speeding  up  and 
"green  hands."  The  labor  turn-over  in  some  of  these  concerns  is  over 
500  per  cent.  To  counteract  this  labor  turn-over  higher  and  still 
higher  wages  are  being  paid^ — often  defeating  their  purpose  by  increas- 
ing turn-over.  Even  patriotism  cannot  overcome  the  bad  influence 
on  the  working  man  of  such  intolerable  conditions. 

The  adoption  of  the  sane  principles  of  industrial  hygiene  by  these 


132  INDUSTRIAL    MEDICINE    AND    SURGERY 

concerns  is  already  taking  place.  The  shipbuilding  yards,  under  the 
direction  of  Major  Philip  Doane,  M.  C.  U.  S.  A.  and  later  under  the 
direction  of  the  U.  S.  Public  Health  Service,  are  completing  a  com- 
prehensive system  in  every  yard.  The  housing  bureau  is  beginning 
to  improve  the  living  conditions  of  these  men.  The  United  States 
Public  Health  Service,  the  National  Research  Bureau  and  the  Commit- 
tee on  Hazardous  Occupations  of  the  Department  of  Labor  are  all 
working  to  improve  the  protection  afforded  to  munition  workers,  and 
others  in  war  industries,  against  occupational  diseases. 

Thus,  under  the  stimulus  of  war,  industrial  medicine  is  making  its 
greatest  advances.  Decreased  sickness,  decreased  accident  rate,  de- 
creased labor  turn-over  have  already  resulted  in  increased  production. 

Production  everywhere  is  the  most  vital  need  of  the  day.  On  it 
depends  the  victory  or  defeat  of  our  armies.  Those  concerns  which 
continue  to  waste  their  man  power  with  a  resulting  diminution  of 
output  should  be  Commandeered. 

Conservation  of  man  power  with  maximum  production  is  the  battle 
cry  of  the  country.  The  adoption  of  Industrial  Health  Services  by 
every  industry  is  the  answer. 


Part  II 
PREVENTION 


CHAPTER  XIV 

PREVENTIVE  MEDICINE  AND  PREVENTIVE 
SURGERY  IN  INDUSTRIES 

Industrial  medicine  and  surgery  consists  of  applying  the  general 
principles  of  medicine  and  surgery  to  a  large  group  of  people  as  a 
unit.  While  individuals  receive  special  medical  or  surgical  care  when- 
eVer  needed,  yet  it  is  apparent  in  every  chapter  of  this  book  that 
prevention  is  the  keynote  of  all  this  work;  -prevention  of  diseases  or 
accidents  among  the  entire  group  of  employees;  prevention  of  undue 
loss  of  time  when  injury  or  disease  assails  an  employee;  prevention  of 
deformities  and  permanent  disabilities,  the  result  of  diseases  or  acci- 
dents; prevention  of  inefficiency  on  the  job  when  traceable  to  some 
physical  condition;  in  fact,  the  prevention  of  everything  which  would 
tend  to  undermine  the  physical  or  mental  welfare  of  the  individual 
or  of  the  entire  group  of  employees. 

In  order  to  accomplish  this  many  of  our  largest  industries  have 
developed  large  staffs  of  capable  physicians  and  surgeons  who  spend 
half  or  all  of  their  time  at  the  plant.  Here  by  being  on  the  job — in 
the  front  line  trench  of  industry — they  are  not  only  in  the  strategic 
position  to  study  and  apply  every  phase  of  prevention,  but  also  to 
practise  the  best  form  of  prevention,  namely,  immediate  and  proper 
medical  and  surgical  care  for  every  sick  or  injured  employee. 

It  is  quite  evident  therefore  that  industrial  medicine  and  surgery 
must  include  many  activities  aside  from  the  specific  treatment  of 
disease. 

As  the  various  chapters  deal  with  some  phase  of  prevention  we  will 
endeavor  here  to  give  only  an  outline  of  the  preventive  work  with  which 
the  industrial  surgeon  must  familiarize  himself  in  order  to  become 
proficient. 

Thinking  of  the  work  therefore  in  terms  of  prevention  we  must 
consider  first,  the  employees;  second,  the  physical  conditions  of  the 
plant;  third,  the  activities  of  the  concern. 

133 


134  INDUSTRIAL    MEDICINE    AND    SURGERY 

I.  PREVENTION  AMONG  THE  EMPLOYEES 

A.  The  applicants  for  work: 

1.  Complete  physical  examination  of: 

(a)  To  protect  the  old  force  from  men  capable  of  spreading 

disease  among  them. 
(6)  To  prevent  the  diseased  applicants  from  going  to  work 

when  work  of  any  kind  would  be  injurious  to  them, 
(c)  To  prevent  applicants  with  physical  handicaps  from  being 

placed  at  hazardous  work  for  them,  or  at  jobs  where  they 

could  not  be  efficient. 

2.  Acquainting  the  applicants  with  all  forms  of  disease  and 
accident  prevention  measures  in  operation  in  the  plant 
immediately  upon  employment. 

(a)  This  prevents  disaster  because  of  ignorance. 
(6)  They  at  once  become  co-operative  units  with  the  existing 
system. 

B.  The  old  employees: 

1.  Complete  physical  examination  of,  either  periodically  or 
whenever  some  condition  arises  showing  the  need  of  a  general 
survey. 

(a)  To  discover  threatened  disease  early,  while  still  prevent- 
able or  curable. 

(6)  To  discover  any  existing  condition  that  makes  the  em- 
ployee prone  to  accident  or  to  cause  accident  to  others. 
It  is  just  as  important  to  survey  the  human  machine  to 
prevent  accidents  as  it  is  to  survey  the  mechanical  appli- 
ances of  the  plant. 

(c)  To  rule  out  those  with  contagious  conditions  to  prevent 
spread  of  disease. 

{d)  To  discover  those  with  handicapped  conditions,  either 
physical  or  mental,  and  to  place  them  at  types  of  work 
which  will  not  be  hazardous  for  them  and  where  they  can 
still  be  efficient  in  spite  of  the  handicap. 

(e)  Examination  should  precede  the  treatment  of  any  con- 
dition, no  matter  how  minor,  thus  preventing  the  admin- 
istering of  the  wrong  type  of  treatment  through  lack  of 
knowledge  of  the  true  condition  or  coincident  disorders. 

2.  Secure  the  co-operation  and  interest  of  employees  in  your 
efforts  for  prevention  of  disease  and  accidents  by : 

(a)  Explaining  the  reasons  for  any  action  taken,  to   each 

individual. 
(6)  Secure  team  work  by  employees'  committees  on  "accident 

prevention,"    "disease  prevention,"  "sanitation  move- 


PREVENTIVE    MEDICINE    AND    SURGERY    IN    INDUSTRIES      135 


the    committees    fre- 
often.     Make     them 


merits."  Add  new  members  to 
quently  and  meet  with  them 
working  committees, 

(c)  Spread  prevention  propaganda  on  every  phase  of  the 
subject  throughout  the  working  force  by  personal  con- 
ferences with  individuals,  by  lectures  and  motion  picture 
shows,  by  use  of  bulletin  boards,  by  terse  facts  printed 
on  backs  of  pay  envelopes,  by  circulars  inserted  in  pay 
envelopes,  by  a  plant  paper  or  bulletin  issued  weekly. 

(d)  Get  the  officials  of  the  concern  interested  and  use  their 
influence  to  put  across  the  ideas. 


Fig.  31. — This  toilet  caused  17  cases  of  typhoid,  two  of  them  fatal.  Loss  in 
wages  and  care  of  the  17  men  amounted  to  $3000.00.  (Typhoid  Bulletin,  issued  by 
Industrial  Surgeons'  Association  of  Washington.) 

(e)    Assist  the  diseased  employees  at  all  times  in  securing 
the  best  forms    of  treatment,  thus  demonstrating  your 
friendly    interest    in    them.     These    become    "medical 
missionaries"  throughout  the  working  force. 
3.  Study  the  relationship  between  employee  and  his  work: 

(a)  Study  this  relationsip  in  every  case  coming  before  you  to 
ascertain  if  "a  round  peg  is  fitted  in  a  round  hole, "  or  if 
the  work  is  incompatible  to  the  employee's  mental  or 
physical  well-being.  This  will  not  only  prevent  a  phys- 
ical or  nervous  breakdown  often  but  will  prevent  in- 
efficiency in  production — an  inefficiency  preventable 
by  transferring  the  man  to  work  for  which  he  is  better 
qualified. 


136 


INDUSTRIAL   MEDICINE    AND    SURGERY 


(h) 


Fatigue  poisoning  from  overwork,  from  monotony  of  the 
same  and  rapidly  repeated  motions  and  other  causes,  will 
be  discovered  and  can  be  prevented. 
Occupational  diseases,  and  latent  possibilities  for  such 
diseases  in  occupations  heretofore  unsuspected,  will  thus 
be  found,  and  steps  taken  to  prevent  them. 
Suggestions  for  the  prevention  of  accidents  will  follow, 
a  study  of  this  relationship  of  man  to  his  work. 
4.  Study  the  relationship  between  employee  and  fellow  employees: 
(a)  Incompatibility  between  an  employee  and  his  foreman  or 
some  fellow  employee  may  be  the  cause  of  a  nervous  or 
physical  breakdown.     The  doctor,  if  he  secures  the  con- 


(0 


id) 


Fig.  32. — "Same  toilet  as  in  Figure  31  rendered  safe  and  fly-proof  at  cost  of  less 
than  $5.00 — after  the  epidemic.  Why  not  before?"  The  Industrial  Surgeons'  As- 
sociation of  Washington  has  carried  on  an  unceasing  warfare  against  typhoid  fever 
among  the  lumbermen  of  the  Northwest. 

fiderices  of  all  employees,  may  be  the  first  to  discover  such 
a  condition  and  by  reporting  it  to  the  proper  authorities 
can  prevent  both  inefficiency  and  the  threatened  break- 
down. 

(6)  Among  girl  employees  one  given  to  infrequent  bathing 
with  resulting  bad  odors  may  be  the  cause  of  nervousness 
and  unrest  among  the  other  employees — a  condition  which 
the  doctor  is  often  called  upon  to  correct  and  which 
demands  diplomacy  in  handling. 

(c)  A  close  study  of  this  relationship  is  necessary  to  prevent 
many  diseases,  many  accidents,  and  much  inefficiency. 
5.  Specific  preventive  measures  rendered  employees: 

(a)  Search  for  focal  infections  and  removal  of  same — special- 
ists such  as  dentists,  nose  and  throat  men  will  be  needed 
on  the  staff  for  this  work. 


PREVENTIVE    MEDICINE    AND    SURGERY    IN    INDUSTRIES      137 

(&)  Recommending  vacations,  change  of  work,  special  treat- 
ment and  other  specific  measures  to  prevent  more  serious 
conditions  from  developing. 

(c)  Vaccination  and  specific  inoculations  against  disease,  as 
antityphoid  prevention. 

(d)  Fumigation  of  working  rooms  after  an  employee  is  found 
with  some  contagious  disease. 

(e)  Recommending  proper  and  immediate  treatment  for  all 
conditions  found  and  supervising  the  employee  to  see 
that  same  is  carried  out. 

I.  Employees'  home  conditions: 

(a)  Unsanitary  home  conditions,  home  worries,  sickness  in 
the  family,  and  many  other  conditions  may  be  the  cause 
of  an  employee's  physical  or  mental  breakdown.  The 
doctor  musb  subtly  study  these  conditions  and  suggest 
needed  remedies  as  a  part  of  his  prevention  program. 
Assistance  must  often  be  obtained  from  the  employer  to 
correct  many  of  them. 

(6)  The  employees  must  be  taughb  to  report  contagious  dis- 
eases in  their  family  in  order  that  the  doctor  can  safe- 
guard the  fellow  employees. 

(c)  Friendly  interest  in  and  constructive  help  to  the  members 
of  an  employee's  family  always  react  favorably  on  the 
health  and  productivity  of  an  employee,  and  therefore 
is  a  definite  part  of  the  prevention  program. 


n.  PREVENTION  AS  RELATED  TO  THE  PHYSICAL 
CONDITIONS  OF  THE  PLANT 

Industrial  Hygiene: 

1.  This  deals  with  the  hygienic  and  sanitary  conditions  of  the 
working  place.  These  must  be  brought  to  the  highest  stand- 
ards in  order  to  prevent  disease  among  the  employees  as  a 
result  of  working  conditions.  This  involves  a  study  of  the 
sanitary  arrangements  of  the  following  and  correction  when 
necessary : 

(a)  The  construction  of  the  building. 

(h)  Arrangements  for  Ughting  and  ventilation. 

(c)  Cleaning  of  the  interior  of  the  buildings. 

(d)  Washing  and  toilet  facilities, 
(e)  Removal  of  fumes  and  dust. 

(f)  Removal  of  refuse  that  would  tend  to  breed  flies,  mos- 
quitoes, and  other  disease  agencies. 


138  INDUSTRIAL   MEDICINE    AND    SURGERY 

(g)  Drainage,  and  sewage  disposal. 

(h)  Proper  protection  of  employees  from  fumes,  or  direct 
contact  with  material  that  is  detrimental  to  health,  and 
all  other  forms  of  protection  from  occupational  diseases. 
B.  Accident  Prevention: 

1.  Changes  in  construction  of  building  so  that  dangerous  stair- 
ways, unprotected  elevator  shafts  or  light  shafts,  unprotected 
platforms  or  other  elevations,  narrow  halls,  sharp  corners, 
doors  opening  the  wrong  way,  or  similar  conditions,  will  not 
tend  to  cause  accidents. 


Fig.  33. — Shell    filling    factory    in    England.      Cleanliness,    good    ventilation,    proper 
lighting,  concrete  floors,  and  respirators  aid  in  production  by  preventing  disease. 


2.  Repair  of  all  broken  boards  in  floor,  broken  window  panes, 
loose  parts  in  walls  or  ceiling,  or  other  dangerous  conditions 
about  the  building 

3.  Removal  of  loose  nails,  boards,  broken  glass,  broken  parts  of 
machinery,  tools  and  all  obstacles  so  placed  as  to  cause 
accidents. 

4.  Careful  arrangement  of  stock,  boxes,  cases,  etc.,  so  that  they 
will  not  fall  and  cause  injury. 

5.  Repair  of  all  tools,  machinery,  and  appliances  used  in  work 
so  that  accidents  will  not  occur  to  the  user  of  the  parts  or  to 
fellow  employees. 

6.  Safeguarding  all  machinery  and  other  physical    appliances 


PREVENTIVE   MEDICINE    AND    SURGERY   IN   INDUSTRIES      139 

about  the  plant  with  special   safety   apparatus   whenever 
possible. 

7.  Protection  of  individuals  from  potential  accidents  when  their 
work  is  hazardous  by  the  wearing  of  special  appliances  as 
goggles,  gloves,  etc. 

8.  Frequent  inspections  of  the  physical  conditions  of  plant  com- 
bined with  inspection  of  physical  conditions  of  the  human 
machines — the  employees — will  result  in  the  prevention  of  the 
majority  of  accidents. 

C.  Fire  prevention,  protection  from  explosions,  from  collapse  of 
buildings  and  other  disasters  of  like  nature  have  never  been 
considered  a  feature  of  medical  or  surgical  work,  but  the  in- 
dustrial surgeon,  responsible  for  the  health  and  safety  of  the 
employees,  must  likewise  become  an  expert  in  the  prevention  of 
these  disasters. 

m.  PREVENTION  AS  RELATED  TO  THE  ACTIVITIES 
OF  THE  INDUSTRY 

A.  General  rules  of  prevention  as  above  laid  down  are  applicable 
to  all  employees  and  to  the  physical  conditions  of  all  industries. 
But  the  industrial  surgeon  by  a  study  of  his  special  industry 
and  the  nature  of  the  work  carried  on  will  discover  many  specific 
preventive  measures  which  he  must  employ. 

B.  The  railway  surgeon  will  meet  with  traffic  and  transportation 
accidents  which  must  be  prevented.  The  physical  condition 
of  each  employee  must  be  carefully  studied  to  see  that  he  is  not 
a  potential  cause  for  accidents  to  others. 

C.  The  mine  surgeon  will  need  to  study  the  hazards  from  gases, 
and  other  conditions  pertinent  to  mine  workers. 

D.  Munition  manufacturing  has  introduced  the  need  of  medical 
men  highly  trained  in  the  prevention  of  certain  forms  of 
poisoning. 

E.  The  physician  in  charge  of  merchandizing  concerns  or  of  large 
office  forces  must  study  and  prevent  disease  from  overcrowding, 
from  sedentary  working  habits,  from  poor  ventilation. 

F.  Thus,  the  industrial  surgeon  must  at  the  earliest  opportunity 
acquaint  himself  with  the  activities  of  the  industry  as  a  whole 
and  of  each  employee  in  order  to  competently  meet  his  specific 
problems  in  prevention. 

From  a  study  of  the  above  outline  it  is  quite  evident  that  prevention 
forms  the  very  foundation  of  all  industrial  medical  and  surgical  work. 
The  industrial  surgeon  who  neglects  to  approach  his  job  from  this 
angle  is  failing  in  his  responsibilities  to  both  the  employee  and 
employer. 


140  INDUSTRIAL   MEDICINE    AND    SURGERY 

The  shortsighted  policy  of  providing  the  cheapest  kind  of  medical 
treatment  to  the  injured  or  occupationally  diseased  employee  without 
expending  any  money  on  the  prevention  of  these  conditions  is  rapidly 
becoming  a  thing  of  the  past.  The  employer  is  realizing  that  cheap 
medical  care  is  often  the  most  expensive  and  that  it  is  far  more  eco- 
nomical to  prevent  than  to  repair. 

The  company  surgeon  of  the  future  must  be  thoroughly  trained  in 
preventive  medicine  and  preventive  surgery  in  their  broadest  aspects. 


CHAPTER  XV 
INDUSTRIAL  HYGIENE 

A  GENERAL  OUTLINE  OF  THE  PROBLEMS 

Every  industry  has  its  specific  problems  of  industrial  hygiene  which 
the  surgeon  in  charge  must  endeavor  to  discover,  master  and  correct 
or  improve  wherever  possible. 

Frequently  some  one  of  the  official  inspectors  from  the  United 
States  Public  Health  Service  or  from  the  Department  of  Labor  report 
that  the  plant  physician  in  a  certain  industry  ''did  not  know  there 
was  even  an  opportunity  for  lead  poisoning  in  the  processes  carried 
on  there;"  or,  "he  didn't  know  a  case  of  phosphorus  poisoning  when 
he  saw  one;"  or,  "he  resented  the  statement  that  there  were  dust  and 
fume  hazards. "  Ignorance  such  as  this  on  the  part  of  the  physician 
who  is  constantly  on  the  job,  and  should  therefore  be  the  best  informed 
in  regard  to  local  conditions,  is  inexcusable.  It  reflects  upon  the  en- 
tire group  of  industrial  physicians  and  surgeons.  Unfortunately, 
the  reputations  of  many  company  physicians  in  the  past  have  been  of 
the  lowest  standard  professionally.  Efforts  to  elevate  the  character 
and  good  name  of  this  group  of  medical  men  by  having  their  work 
recognized  everywhere  as  of  the  highest  standard  are  being  made. 
Each  surgeon  in  industry  must  do  his  part. 

It  is  the  solemn  duty  of  every  plant  physician  therefore  to  so  im- 
prove the  sanitary  and  other  health  conditions  in  his  industry  to  the 
end  that :  the  employees  will  have  the  greatest  possible  protection,  the 
employers  will  receive  the  greatest  possible  benefits  from  these  im- 
proved conditions,  and  the  health  work  in  the  plant  will  be  a  model  to 
others.  Such  an  effort  on  the  part  of  every  company  physician  would 
be  the  greatest  public  health  movement  ever  inaugurated  in  this  coun- 
try, and  the  men  responsible  for  such  a  movement  would  take  their 
places  in  the  foremost  ranks  of  our  profession. 

It  is  impossible  to  discuss  all  the  specific  problems  of  Industrial 
Hygiene  which  each  plant  physician  will  encounter  in  his  industry, 
but  the  general  conditions  which  must  be  considered  in  every  case  are 
herewith  outlined. 

Industrial  Hygiene  Problems  to  be  considered  in  every  concern 
come  under  one  of  these  four  groups :  the  nature  of  the  industry,  the 
physical  conditions  of  the  plant  and  its  surroundings,  the  physical 

141 


142  INDUSTRIAL   MEDICINE    AND    SURGERY 

condition    of    the    employees,    and    the    health    conditions    of    the 
community. 

I.  Nature  of  the  Industry  and  the  various  Processes  and  Occupa- 
tions carried  on : 

A.  What  specific  health  hazards  are  present? 

1.  A  study  of  all  occupations,  the  material  handled,  the 
processes  and  motions  involved  and  every  other  considera- 
tion which  could  influence  health  is  necessary, 

B.  Hours  of  Work: 

1.  Are  they  excessive,  acting  as  a  detriment  to  health  of 
employees? 

2.  Are  rest  periods,  changes  of  occupations  and  other  pro- 
cedures allowed  so  as  to  avoid  fatigue? 

3.  Is  the  night  work  especially  hazardous  to  the  employees? 

4.  Are  Sunday  and  holiday  rests  observed? 

5.  Are  washing  periods,  periods  for  going  to  toilet  and  other 
needed  rest  periods  taken  on  company  time? 

6.  Are  the  employees  content  with  these  conditions? 

C.  Nature  of  the  Work: 

1.  Is  the  work  of  such  a  nature  as  to  cause  constant  over- 
exertion? 

2.  Are  labor  saving  devices  utilized  wherever  possible? 

3.  Are  the  employees  instructed  in  the  best  methods  of 
doing  the  work  so  as  to  avoid  hazards? 

4.  Are  "bell-cow,"  "pacemakers"  or  driving  methods  used 
which  may  add  to  the  exertion,  nervous  strain,  or  other 
fatigue  conditions  of  the  employees?^  Is  "piece-work," 
as  carried  on,  detrimental? 

5.  Are  safety  devices  used? 

6.  Are  protection  methods  against  occupational  diseases, 
such  as  respirators,  dust  exhausts,  hoods  for  removal  of 
dangerous  gases  and  fumes  and  all  other  devices  in  place 
and  used  by  the  employees? 

7.  Are  the  hazardous  processes  separated  from  the  non- 
hazardous  so  that  the  employees  in  the  latter  are  not 
unduly  exposed? 

8.  Have  you  made  careful  studies  to  discover  other  occupa- 
tional hazards,  not  usually  classified  in  dangerous  occu- 
pations, and  reported  the  same? 

9.  Have  you  carefully  instructed  the  management  and  em- 
ployees in  all  hazards  represented  by  their  work  and  the 

*The  "bell-cow"  is  the  fastest  worker  in  a  department  pointed  to  as  an  ex- 
ample for  the  other  employees. 


INDUSTRIAL    HYGIENE  143 

best  means  of  prevention?     Are  new  employees  instructed 
in  the  same  before  going  to  work? 
D,  Wages: 

1.  The  right  of  the  plant  physician  to  be  concerned  in  wages 
is  often  questioned  by  the  management.  However  when 
insufficient  wage  is  a  direct  or  indirect  cause  for  lowered 
health  conditions  among  the  employees  it  is  the  duty  of 
the  plant  physician  to  point  out  these  facts  to  the  manage- 
ment. Such  data  should  be  carefully  prepared  and  be 
irrefutable. 
II.  Physical  Conditions  of  the  Plant  and  its  Surroundings: 
A.  Nature  and  Construction  of  Buildings: 

1.  Purpose  building  is  used  for? 

2.  Type  of  construction? 

(a)  Is  it  sufficiently  well  built  to  standj  the  stress  and 
strain  placed  upon  it? 

3.  Are  the  stairways  strong,  sufficiently  wide,  adequate  and 
protected  against  falls? 

4.  Are     elevators     adequate,     inspected    and     sufficiently 
protected? 

5.  Floors: 

(a)  Type  of  construction  and  nature  of  supports? 

(6)  If  wooden  do  they  absorb  dangerous  material  which 

may  be  given  off  in  form  of  dust  thus  adding  to 

hazards? 

(c)  Are  they  level  and  well  drained? 

(d)  Are  they  clean?  Is  cleaning  process  done  with  least 
dust  hazard? 

(e)  Are  they  kept  in  good  repair? 

6.  Walls  and  Partitions: 

(a)  What  is  nature  of  construction? 
(6)  Are  the  rooms  divided  by  too  many  partitions  thus 
making  dark  corners  and  non-ventilated  areas? 

(c)  Are  the  walls,  partitions  and  ceilings  clean  and  of 
proper  color  to  be  least  injurious  on  eyes? 

(d)  Are  ceilings  too  low? 

(e)  Are  the  rooms  unnecessarily  damp? 

7.  Fire  Protection: 

(a)  Are  means  of  escape  from  buildings  in  case  of  fire 
adequate? 

(6)  Is  there  a  sprinkler  system? 

(c)  Are  fire  extinguishers  provided  and  in  sufficient  num- 
bers? 

8.  Is  the  building  kept  in  a  sanitary  condition? 


144  INDUSTRIAL   MEDICINE    AND    SURGERY 

B.  Surroundings: 

1.  Is  the  building  located  in  a  sanitary  place? 

2.  Are  the  grounds  clean,  well  drained  and  kept  free  of 
refuse  and  other  material  detrimental  to  health? 

3.  Does  proximity  of  other  buildings  interfere  with  ven- 
tilation and  sanitary  conditions? 

4.  Do  dangerous  fumes,  dusts,  etc.  from  nearby  industries 
interfere  with  health  conditions  in  your  plant? 

C.  Ventilation: 

1.  Is  there  overcrowding  of  the  rooms  or  is  air  space  suf- 
ficient? 

2.  If  ventilation  is  natural  is  there  sufficient  window  space, 
stairway  space  and  elevator  and  air  shafts  to  furnish 
adequate  ventilation? 

(a)  Are  these  spaces  kept  unobstructed? 

3.  Is  there  any  artificial  ventilation  system  used? 

(a)  Are  the  suction  fans  and  conducting  pipes  adequate? 
(6)  Are  blower  systems  installed  over  dust  producing 
processes  adequate? 

(c)  If  air  is  washed  and  used  again  is  process  satis- 
factory? 

(d)  Does  use  of  natural  system  with  artificial  interfere  in 
latter?     If  so,  which  is  best  system  to  use? 

(e)  Is  the  foul  air,  dust,  etc.  discharged  so  as  not  to  re- 
enter open  windows  again? 

D.  Humidity: 

1.  Any  artificial  means  needed  to  keep  humidity  at  proper 
ratio  to  temperature? 

2.  Are  "wet-bulb"  thermometer  tests  made  frequently? 

E.  Temperature: 

1.  What  is  nature  of  heating  plant? 

2.  Is  temperature  kept  fairly  constant? 

3.  Is  there  exposure  to  excessive  heat  and  cold? 

(a)  What  precautions  are  taken  to  protect  employees  in 
this  case? 

4.  Is  an  expert  on  ventilation,  temperature  and  humidity 
employed  or  consulted  to  make  sure  that  these  are  ade- 
quate? 

r.  Fumes  and  Gases: 

1.  If  present  from  any  of  the  processes  are  proper  arrange- 
ments made  for  their  removal? 

2.  Are  the  employees  in  other  parts  of  the  building  pro- 
tected from  these? 


10 


INDUSTRIAL   HYGIENE  145 

G.  Dusts: 

1.  Are  proper  facilities  employed  for  removal  of  same? 

2.  Are  employees  in  dusty  occupations  protected  by  res- 
pirators? 

3.  Are  frequent  changes  from  dusty  occupations  permitted 
the  employees? 

4.  Is  dry  sweeping  permitted? 

5.  Have  you  made  a  careful  study  of  the  hazards  of  the 
specific  dusts  in  your  industry? 

H.  Illumination: 

1.  Natural: 

(a)  Is  the  number  of  windows  and  light  shafts  sufficient? 
(6)  Are  the  windows  kept  clean? 

2.  Artificial: 

(a)  Direct  or  indirect  lighting  system? 

(6)  Are  the  lights  properly  placed  and  of  uniform  type? 

(c)  Are  the  bulbs  and  lamps  kept  clean  and  properly 
shaded? 

(d)  If   spot   lights   are    used    do    they    interfere    with 
adjacent  employees,  adding  to  their  eye-strain? 

(e)  Are  dark  areas  where  employees  must  pass  through 
illuminated  ? 

3.  Do  employees  complain  of  eye-strain  and  other  effects  of 
inadequate  lighting? 

I.  Excessive  Noises : 

1.  Have  efforts  been  made  to  reduce  excessive  noise? 

2.  Are  the  excessively  noisy  occupations  separated  from  the 
other  processes? 

3.  Have  you  studied  the  effect  of  these  noisy  occupations 
upon  the  employees  engaged  in  the  same,  especially  as  to 
hearing? 

4.  Are  the  employees  engaged  in  the  sedentary  work  re- 
moved from  the  strain  of  excessive  noise? 

J.  Protection  against  spitting  and  refuse: 

1.  Are  instructions  against  promiscuous  spitting  ample  and 
enforced? 

2.  Is  sufficient  number  of  cuspidors  provided? 

3.  Are  these  cleaned  daily  and  is  the  cleaning  thorough? 
(a)  Are  they  handled  by  hand  or  are  the  porters  protected 

from  handling  the  same? 
(&)  Is  any  effort  toward  sterilization  made  and  is  this 
successful? 

4.  Are  receptacles  for  refuse  provided  and  are  these  removed 
and  cleansed  daily? 


146 


INDUSTRIAL   MEDICINE    AND    SURGERY 


INDUSTRIAL    HYGIENE  147 

5.  Are  provisions  made  for  the  obtaining  and  disposal  of 
sanitary  napkins  by  women  employees? 
K.  Washing  Facilities:  '■ 

1.  Is  running  water  provided? 

2.  Is  number  of  faucets  sufficient  for  number  of  employees 
using  them? 

3.  Are  stationary  bowls  or  troughs  with  continuous  flow 
used  and  which  is  safer  in  your  industry? 

4.  Are  arrangements  made  for  cleansing  stationary  bowls? 

5.  Are  shower  baths  provided  when  necessary? 

6.  Are  individual  towels  and  soap  furnished  the  employees 
or  do  they  provide  these  for  themselves?  Has  the  use 
of  roller  towels  been  abandoned? 

7.  Are  the  wash  rooms  clean,  light  and  located  near  the 
toilets  and  locker  rooms? 

8.  Have  the  employees  been  instructed  in  the  need  of  wash- 
ing before  eating? 

L.    Toilet  Facihties: 

1.  Are  sufficient  number  of  toilets  provided? 

2.  Are  they  clean,  light,  well  ventilated  and  kept  in  good  re- 
pair and  in  a  sanitary  condition  at  all  times? 

3.  Are  they  inspected  daily? 

4.  Have  all  modern  improvements  furnishing  protection 
against  disease  been  made? 

5.  If  privies  are  used  are  these  plentiful,  clean  and  protected 
from  flies?  Are  they  sufficiently  removed  from  working 
places? 

6.  Is  sewage  removal  suitable  and  sanitary? 
M.  Locker  Facilities : 

1.  Are  the  best  type  of  lockers  furnished? 

2.  Is  the  locker  room  airy,  light  and  kept  clean? 

3.  Is  the  smell  from  sweaty  and  dirty  clothes  obnoxious? 

4.  Is  any  arrangement  made  for  drying  the  clothes  if  soaked 
by  rain  or  snow  on  the  way  to  work?  (This  is  especially 
helpful  in  the  case  of  women  employees.) 

5.  Are  the  locker  rooms  periodically  fumigated? 
N.    Eating  Facihties: 

1.  Is  a  plant  restaurant  operated? 

2.  Is  food  prepared  under  best  sanitary  arrangements? 

3.  Are  the  chefs,  waitresses  and  others  handling  the  food 
periodically  examined? 

4.  Are  frequent  inspections  made  ? 

5.  If  no  restaurant  at  plant  then  is  a  proper  place  for  eating 
of  lunches  provided? 


148  INDUSTRIAL    MEDICINE    AND    SURGERY 

6.  Is  an  effort  made  to  get  employees  out  of  working  rooms 
at  lunch  hour? 

0.  Drinking  Facilities: 

1.  Has  the  source  of  water  supply  been  ascertained  and  in- 
spiected? 

2.  Has  the  water  been  chemically  and  bacteriologically  ex- 
amined and  made  safe? 

3.  Is  it  protected  from  pollution? 

4.  If  a  storage  tank  is  used  is  it  kept  clean? 

5.  Is  the  use  of  common  drinking  cup  abandoned? 

6.  Are  bubbling  fountains  used  and,  if  so,  of  a  type  to  pre- 
vent spread  of  disease? 

7.  Is  number  and  location  of  drinking  places  adequate  and 
properly  distributed  so  that  employees  will  be  furnished 
all  the  water  needed? 

P.    Recreational  Facilities: 

1.  Does  the  industry  provide  athletic  fields,  gymnasium, 
recreation  rooms,  library  and  other  facilities  for  the  em- 
ployees to  secure  proper  and  necessary  recreation? 

2.  Do  the  employees  take  advantage  of  them? 

3.  Does  the  medical  staff  take  an  active  interest  in  them? 

Q.    Rest  Rooms: 

1.  Are  rest  rooms  with  cots  furnished  for  employees  need- 
ing them  because  of  fatigue  or  sickness  developing  while 
at  work?  (These  are  especially  needed  by  women 
employees,  but  should  be  provided  for  men  also.) 

2.  Are  these  placed  in  the  most  restful  surroundings? 

3.  Is  a  proper  person  in  attendance? 
R.  Doctor's  Office  and  First  Aid  Station: 

1.  Is  the  number  of  employees  and  the  nature  of  the  work 
sufficient  to  warrant  a  central  doctor's  office  at  the  plant? 

2.  Are  first  aid  stations  needed  in  other  parts  of  the  plant? 

3.  If  no  doctor's  office  is  needed  then  is  a  first  aid  station 
provided? 

4.  Is  the  equipment  of  the  doctor's  office  and  aid  stations 
sufficient  for  the  best  work? 

5.  Are  the  first  aid  men  carefully  instructed  in  their  duties? 

6.  Are  they  used  for  first  aid  only,  or  is  an  effort  made  to 
have  them  replace  doctors — a  cheap  form  of  service? 

III.  Physical  Conditions  of  the  Employees: 
A.  Physical  Examinations: 

1.  Are  the  applicants  for  work  examined  and  assigned  to  jobs 

according  to  their  physical  qualifications? 


INDUSTRIAL    HYGIENE  149 

2.  Are  the  employees  examined  periodically  when  engaged  in 
•  occupations  with  disease  hazards? 

3.  Are  all  old  employees  examined  at  intervals? 

4.  Is  the  working  force  protected  from  the  diseased  fellow  em- 
ployee when  necessary? 

5.  Is  a  careful  study  made  of  the  relationship  between  occupa- 
tions and  the  employees  physical  and  mental  make-up? 

B.  Medical  Care: 

1.  Is  every  preventive  measure  against  both  disease  and  injury 
installed  and  in  use? 

2.  Is  complete  medical  care  furnished  the  employees  and  is  this 
the  best  system? 

3.  Is  proper  supervision  of  the  sick  employee  maintained  to 
see  that  he  receives  the  best  treatment  possible?  •     . 

4.  Is  the  medical  staff  competent  and  sufficient  in  number? 

5.  Are  proper  hospital  facilities  arranged  for? 

6.  Are  competent  industrial  nurses  employed? 

C.  Provisions  for  Contagious  Cases: 

1.  Is  there  any  plan  in  force  to  discover  contagious  diseases 
early? 

2.  Are  contagious  cases  isolated  while  awaiting  transportation 
home? 

3.  Is   the   public  properly  protected  against  these  contagious 
cases  during  their  transportation  home? 

4.  Are  the  rooms  where  contagious  cases  develop  fumigated? 

D.  Recreation,  Vacations,  etc.: 

1.  Is  proper  recreation  prescribed  for  employees  to  counteract 
fatigue  and  other  work  conditions? 

2.  Are  vacations  recommended  to  prevent  threatened  break- 
downs? 

3.  Are  occupations  changed  on  recommendation  of  physician  to 
prevent  breakdowns? 

E.  Have  the  employees  been  properly  instructed  in  all  matters 
tending  to  improve  health  conditions? 

F.  Are   the   employees   vaccinated,    inoculated   against   typhoid 

fever  or  other  diseases? 

G.  Are*  efforts  made  to  relieve  the  employees  of  worries  over 
sickness,  debt  and  other  family  conditions? 

H.  Has  every  effort  been  made  to  secure  proper  co-operation  be- 
tween the  management,  the  employees  and  the  medical  staff  to 
improve  health  conditions? 
IV.  Health  Conditions  of  the  Community: 

A.  Co-operation  between  municipal  health  department  and  the 
medical  staff  of  the  industry: 


150  INDUSTRIAL    MEDICINE    AND    SURGERY 

1.  Are  contagious  diseases  properly  reported? 

2.  Does  the  health  department  notify  the  plant  physician  of 
contagious  diseases  in  the  families  of  employees? 

3.  Do  you  co-operate  with  the  health  department  to  improve 
conditions  about  the  plant  and  its  surroundings? 

4.  Do  you  interest  yourself  in  the  health  conditions  of  the 
community? 

B.  Home  Conditions: 

1.  Are  efforts  made  to  improve  the  housing  conditions  of  the 
employees  in  your  industry? 

2.  Do  the  nurses  visit  the  homes  of  employees  and  endeavor 
to  improve  conditions  therein? 

C.  Community  Conditions: 

1.  Does  the  management  interest  itself  in  community  organiza- 
tions such  as  churches,  schools,  hospitals,  clubs,  Y.  M,  C.  A., 
Y.  W.  C.  A.,  amusements,  etc.? 

3.  Are  proper  hospital,  dental  and  medical  facilities  furnished 
the  families  of  employees? 

4.  Are  there  restrictions  on  saloons  in  the  neighborhood  of  the 
industry  and  other  protective  measures  against  the  excessive 
use  of  alcohol? 

D.  Is  there  co-operation  between  local  industrial  concerns  to  secure 
the  best  possible  conditions  in  the  community  as  regards 
the  health,  comfort  and  welfare  of  all  wage-earners? 

No  physician  in  charge  of  the  human  maintenance  department  of 
an  industry  has  fulfilled  his  mission  until  he  has  carefully  considered 
the  above  problems  in  their  relation  to  his  work  and  taken  steps  to 
provide  for  their  best  solution. 

The  succeeding  chapters  will  set  forth  in  more  or  less  detail  some 
of  the  specific  problems  met  with  in  industrial  hygiene. 


CHAPTER  XVI 
INDUSTRIAL  HYGIENE 

SPECIFIC  PROBLEMS 

For  the  technical  discussion  of  many  of  the  specific  problems  of 
industrial  hygiene  the  reader  is  referred  to  the  various  works  on  sani- 
tary engineering.  In  fact  physicians  will  find  that  sanitary  engineers 
are  of  the  greatest  value  in  establishing  high  standards  of  hygiene  and 
there  should  be  much  closer  co-operation  between  the  two  professions. 
In  the  army,  sanitary  engineers  working  with  the  medical  officers  have 
proven  invaluable  in  developing  military  sanitation.  Such  engineers 
are  already  a  definite  part  of  the  organization  of  many  industries. 

Dr.  Paul  Fox,  who  has  devoted  considerable  time  to  the  plant 
sanitation  in  one  of  the  large  industries  of  Chicago,  has  achieved  excel- 
lent results  by  practical  methods  of  meeting  many  of  these  problems. 
The  author  is  indebted  to  him  for  most  of  the  data  concerning  ventila- 
tion and  disinfection.  Fox  says,  "the  underlying  principles  and  the 
question  of  right  and  wrong  in  sanitation  are  distinctly  a  part  of  the 
physician's  work.  It  is  therefore  imperative  that  he  have  some  knowl- 
edge of  the  essentials  of  sanitation." 

Ventilation 

By  ventilation  we  mean  the  supplying  of  air  in  sufficient  quantities 
and  of  proper  quality  to  make  the  room  a  healthful  place  in  which  to 
work.  Perhaps  no  one  factor  reduces  the  efficiency  of  a  workman  so 
noticeably  as  does  the  lack  of  proper  and  adequate  ventilation.  "Bad 
air"  causes  many  complaints  among  employees  and  often  causes  an 
entire  department  to  lag  behind  in  its  production.  It  is  therefore  of 
great  economic  value  to  have  the  room  so  ventilated  that  the  air  will 
always  be  comfortable  and  invigorating,  thus  avoiding  any  mental 
or  physical  depression.  In  main  we  may  say  that  a  comfortable 
atmosphere  is  a  healthful  atmosphere,  so  that  our  problem,  therefore, 
is  largely  one  of  making  the  room  comfortable  for  the  particular  type 
of  work  which  is  being  done. 

In  order  to  have  a  clear  understanding  of  what  constitutes  "bad 
air,"  it  is  necessary  to  have  some  knowledge  of  the  normal  function 
of  air,  and  of  the  means  by  which  these  functions  normally  maintain 
body  comfort. 

151 


152  INDUSTRIAL   MEDICINE    AND    SURGERY 

It  is  commonly  known  that  air  has  two  principal  functions;  one,  is 
the  physical,  and  the  other  chemical.  By  the  physical  property  of 
air  we  mean  the  absorption  or  regulation  of  the  body  heat,  while  the 
chemical  property,  is  the  organization  or  the  supplying  of  oxygen  to 
the  blood.  If  the  air  in  a  room  is  not  constantly  changed  it  soon 
becomes  unable  to  perform  either  of  these  functions.  The  oxygen 
gradually  is  exhausted  and  the  air  becomes  of  such  temperature  and 
humidity  that  it  is  impossible  for  it  to  absorb  the  body  heat.  It  has 
been  thoroughly  demonstrated  that  the  physical  factor  causes  distress 
far  in  advance  of  the  chemical — in  other  words,  a  fault  in  the  tempera- 
ture, humidity  or  motion  of  the  air  will  cause  distressing  symptoms, 
long  before  the  lack  of  oxygen  or  the  excess  of  carbon  dioxid  becomes 
apparent. 

Cojn plaints  of  "bad  air"  are  therefore  in  the  vast  majority  of 
causes  due  to  the  fact  that  the  air  in  the  room  is  of  such  quality  that 
absorption  of  body  heat  is  retarded.  The  former  theory  that  "bad 
air"  was  air  in  which  the  oxygen  was  deficient  or  the  carbon  dioxid 
in  excess,  has  long  since  been  abandoned.^  It  is  true  that  in  certain 
industries  poisonous  gases  are  given  off  which  cause  toxic  symptoms 
to  the  employees.  However,  this  factor,  although  related  to  ventilation, 
properly  belongs  under  the  heading  of  occupational  diseases  and  need 
not  be  discussed  in  this  connection. 

The  present  day  conception  of  the  principles  of  ventilation  are 
clearly  set  forth  in  the  following  outline  by  Dr.  Thomas  R.  Crowder.^ 

1.  All  trustworthy  evidence  goes  to  show  that  the  normal  expired 
air  contains  no  volatile  poison  and  that  it  is  not  capable  of  harming  the 
human  organism  when  rebreathed  under  the  ordinary  conditions  of 
ventilation. 

2.  The  increase  of  carbon  dioxid  and  the  decrease  of  oxygen  have 
nothing  to  do  with  the  ventilation  problem  under  normal  conditions, 
or  with  the  subjective  or  objective  effects  of  close  air.  Carbon  di- 
oxid is  a  necessary  constituent  of  the  air  of  the  lungs;  it  is  not  to  be 
considered  as  a  poison  or  the  index  of  a  poison.  Its  proportion  in  the 
air  of  a  room  is  a  convenient  and  fairly  accurate  index  of  the  quantita- 
tive air  supply. 

3.  Air  performs  for  the  body  a  physical  function  (heat  abstrac- 
tion) which  is  quite  as  important  as  its  chemical  function  (oxygen- 
supplying). 

1  Report  of  the  Committee  on  the  Ventilation  of  Cars.  Transaction  of  the 
Section  on  Preventive  Medicine  and  Public  Health.,  Am.  Med.  Association, 
Chicago,  19^1,  P-  177.  Paul:  Ztschr.  f.  Hyg.,  1905,  xlix,  405;  Flugge:  Ztschr.  f. 
Hyg.,  1905,  xlix,  363. 

2  Crowder:  Study  of  Ventilation  of  Sleeping  Cars.  Archives  of  Internal 
Medicine,  Jan.,  1913,  Vol.  ii,  p.  66. 


INDUSTRIAL    HYGIENE  153 

4.  The  ordinary  defects  of  ventilation  lie  with  the  physical  func- 
tion of  the  air  and  not  with  the  chemical. 

5.  Temperature,  humidity  and  air  movement  are  the  physical 
qualities  of  the  air  which  are  of  importance  in  this  relation. 

6.  The  success  of  ventilation  depends  on  whether  or  not  these 
physical  qualities  of  the  air  are  so  regulated  as  to  maintain  its  physical 
function  of  heat  abstraction  without  embarrassment  to  the  reflex  mech- 
anism for  the  regulation  of  the  body  temperature.  "  The  good  effects  of 
efficient  ventilation  and  outdoor  air  depend  on  the  coolness,  the  rela- 
tive humidity  and  the  motion  of  the  air  and  the  ceaseless  variation  of 
these  qualities." 

It  will  be  seen  from  what  has  been  said  above,  that  for  all  practical 
purposes  in  ventilation,  we  can  entirely  disregard  the  oxygen  and  carbon 
dioxid  content,  and  look  entirely  to  the  physical  condition  of  the  air. 
There  are  three  factors  which  have  to  do  with  the  successful  perfor- 
mance of  the  physical  functions  of  the  air — namely,  temperature, 
humidity  and  air  motion.  These  three  factors  are  interdependent  and 
naust  all  enter  into  any  question  of  ventilation.  Thus,  when  the  humid- 
ity is  low,  or  the  air  motion  is  great,  a  higher  temperature  is  required 
than  when  with  high  humidity  and  slower  motion. 

Temperature 

Temperature  is  by  far  the  most  important  of  these  three  factors 
and  although  intimately  associated  with  humidity  and  air  motion  we 
can,  for  all  practical  purposes,  say  that  if  the  temperature  is  properly 
regulated  there  will  rarely  be  any  complaint  of  poor  ventilation.  A 
stuffy  room  usually  means  a  room  in  which  the  temperature  is  too  high, 
thus  interfering  with  the  absorption  of  body  heat.  In  rooms  where  the 
occupants  are  relatively  inactive,  the  temperature  should  never  be  over 
70°F.  whereas  if  it  is  kept  between  64°  and  68°F.  it  wiU  be  of  the  great- 
est comfort.  Where  physical  labor  of  moderate  degree  is  performed  a 
temperature  of  60°  will  be  most  acceptable.  Therefore  the  character  of 
the  work  or  the  amount  of  exercise  being  taken  by  the  occupants  of 
the  room,  must  be  taken  into  consideration  when  determining  the 
proper  degree  of  temperature  to  be  maintained. 

Humidity 

The  relative  amount  of  moisture  in  the  air  goes  hand  in  hand  with 
the  temperature  of  the  air.  As  nearly  as  can  be  estimated  the  rela- 
tive humidity  of  the  air  should  be  about  50  per  cent,  (this  may  be 
measured  by  the  wet  and  dry  bulb  or  Taylor  Hygrodeik,  or  by  the 
Sling  Psychrometer).  However,  the  exact  per  cent,  of  humidity  is 
a  much  debated  question,  and  depends  directly  upon  the  temperature 
of  the  air,  and  upon  the  air  motion.     At  80°F.  with  moderate  humid- 


154  INDUSTRIAL    MEDICINE    AND    SURGERY 

ity'or  at  70°  to  73.5°F.  with  high  humidity,  practically  all  persons 
begin  to  show  evidence  of  depression,  headache,  dizziness  or  a  tendency 
to  nausea.  The  ideal  condition,  therefore,  would  be  a  moderate  tem- 
perature, not  above  70°F.  and  a  moderate  humidity  not  above  50 
per  cent.  The  advisability  of  adding  moisture  to  the  air  during  the 
winter  months  is  a  much  disputed  question,  and  one  which  has  not  as 
yet  been  put  upon  a  practicable  basis  as  far  as  large  institutions  are 
concerned.  From  the  theoretical  standpoint  it  stands  to  reason,  that 
the  evaporation  of  water  in  a  room  during  the  winter  months  should 
be  of  great  value.  The  cold  air,  as  well  known,  has  a  lower  point 
of  saturation  than  warm  air.  If,  therefore,  we  take  the  cold  winter 
air  into  the  room  and  heat  it  we  cause  a  change  which  is  similar  in  effect 
to  a  reduction  in  the  amount  of  moisture.^ 

In  this  way  we  have  an  atmosphere  which  must  be  heated  to  an 
excessively  high  degree  in  order  that  it  may  be  comfortable;  thus 
producing  air  which  is  both  overheated  and  overdry. 

It  is  claimed  by  many  authorities  that  the  lack  of  moisture  in  the 
air  during  the  winter  months  is  responsible  for  many  of  the  cases  of 
colds,  rhinitis,  sore  throats,  etc.,  which  are  so  prevalent  during  these 
months.  As  a  matter  of  fact  it  is  the  excessive  heat  which  is  used  to 
keep  the  dry  air  comfortable  which  is  the  main  factor  in  lowering  the 
resistance.  There  is  also  a  possible  factor  of  too  rapid  absorption  of 
moisture  from  the  body  especially  the  nose  and  throat,  which  may 
be  a  factor  in  lowering  resistance. 

It  is  a  well  established  fact  that  with  a  relatively  high  humidity  a 
lower  temperature  will  be  found  more  comfortable.  Thus  it  will  be 
found  that  dry  air  heated  to  72°,  74°,  or  even  80°F.  will  be  less  comfort- 
able and  wOl  appear  more  chilly  than  a  temperature  of  66°  or  68°F. 
when  there  is  a  greater  degree  of  moisture  in  the  air  of  the  room.  In  a 
room  in  which  the  air  is  overheated  and  overdry  the  least  movement 
of  the  air  gives  the  sensation  of  drafts.  If  the  moisture  is  increased 
and  the  temperature  lowered  the  air  will  give  the  impression  of  balmi- 
ness  and  its  movements  unless  of  considerable  force,  will  cease  to  be 
noticed  as  drafts. 

It  may  be  said,  therefore,  that  evaporation  of  water  is  advisable, 
when  it  is  found  that  the  relative  humidity  is  low  (below  50°)  or  that 
it  is  necessary  to  maintain  an  excessively  high  temperature  (above  70°) 
to  keep  the  room  comfortable. 

The  following  chart  illustrates  the  method  of  determining  what  is 
at  fault  when  there  is  a  complaint  of  poor  ventilation.  It  wUl  be 
seen  that  the  temperature  was  constantly  too  high  (averaging  over 

1  Hill  and  Flack:  Influence  of  Ozone  in  Ventilation.  Journal  Royal  Society 
of  Arts,  London,  Feb.  9,  1912,  p.  344.  Roseman  and  Amoss:  Organic  Matter  in 
the  Expired  Air.     Journal  Medical  Research,  1911,  xxv,  35. 


INDUSTRIAL   HYGIENE 


155 


72°F.).  This  together  with  a  relatively  high  humidity  made  a  very 
uncomfortable  room.  In  this  case  the  difficulty  was  entirely  overcome 
by  regulating  the  thermostat  so  that  the  temperature  did  not  exceed 

68°F. 


Date 

Time 

9  A.M 

11  A.M 

11/21/16 

2P.M 

Date 

5P.M 

Time 

9A.M 

11/22/16 
(Foggy  day) 

11  AM 
2P.M 

5P.M 

Temp. 
72 

73 

70 
73 

Temp. 
71 

74 

75 
74 


Humidity 

58 
48 


388  employees  in  room 


48 
55 

Humidity 

62 
59 

48 
59 


416  employees  in  room 


Air  Motion 

From  what  has  been  said  above,  it  is  evident  that  air  motion  is 
intimately  associated  with  temperature  and  humidity.  If  the  tem- 
perature and  humidity  are  high,  as  in  the  summer  months,  it  is  abso- 
lutely necessary  to  have  air  motion  to  maintain  comfort.  Whereas, 
with  low  temperature  and  low  humidity  even  the  slightest  air  currents 
cause  marked  effect  upon  metabolism  and  the  loss  of  body  heat. 
In  rooms  where  the  temperature  and  humidity  are  high,  or  where 
the  temperature  is  high  and  the  humidity  relatively  low  it  will  be 
necessary  to  have  air  motion  in  order  to  have  comfort.  Just  what 
rate  of  motion  is  necessary  has  not  been  clearly  worked  out  and  no 
standard  can  be  established  because  effect  of  the  air  motion  is  absolutely 
dependent  upon  the  temperature  and  humidity  of  the  air.  Professor 
Hill  states  that  in  his  opinion  slight  but  constant  changes  in  the  tem- 
perature and  motion  of  the  air  lead  to  constant  readjustments  of  the 
heat  regulating  mechanism  of  the  body,  and  are  very  important  in 
obtaining  good  results.  It  is  his  opinion  that  the  impulsion  of  hot 
air  into  a  room  is  the  ''most  objectionable  of  all  systems  of  ventila- 
tion, and  that  cold  air  entering  in  small  jets,  heated  by  direct  radiation, 
is  ideal." 

Adequate  ventilation  has  been  recently  defined  by  the  Health 
Department  of  New  York  City  as  follows:  "(1)  The  temperature  of 
rooms  during  periods  of  occupancy  should  register  preferably  from  60° 
to  70°F.  at  all  times,  except  when  the  outside  temperature  exceeds 
60°.  This  does  not  apply  to  rooms  used  for  special  purposes,  such  as 
industrial  places  where  high  or  low  temperatures  are  essential  and  un- 
avoidable. (2)  The  relative  humidity  in  occupied  rooms  should  not 
exceed  70  per  cent.,  except  when  the  outside  (wet)  bulb  temperature 


156  INDUSTRIAL   MEDICINE    AND    SURGERY 

exceeds  59°.  (3)  The  carbon  dioxid  in  occupied  rooms  of  all  classes 
should  not  at  any  time  exceed  10  parts  in  10,000  volumes  of  air  in  any 
part  of  the  occupied  spaces  of  the  rooms.  (4)  The  dust  particles 
in  the  air.  of  occupied  rooms  in  all  classes  of  buildings  should  not  exceed 
1,000,000  per  cubic  foot.  (5)  The  bacterial  content  should  not  exceed 
100  per  cubic  foot.  (6)  The  air  of  occupied  rooms  should  be  free 
from  objectionable  odors." 

Disinfection 

Fox  again  says:  "The  industrial  physician  should  have  complete 
supervision  over  all  methods  of  disinfection.  He  should  be  in  a  posi- 
tion to  pass  judgment  on  every  process  which  is  in  use  and  to  make 
tests  which  will  prove  the  efficiency  or  the  inefficiency  of  any  given 
process.  It  is  clearly  evident  then  that  we  must  familiarize  ourselves 
with  the  accepted  methods  in  order  to  avoid  some  of  the  errors  which 
are  made  along  this  line. 

"  Perhaps  in  no  other  branch  of  preventive  medicine,  has  there  been 
such  a  great  fluctuation  of  opinion  as  in  that  of  disinfection.  The 
fact  that  there  is  such  a  large  variety  of  disinfectants  on  the  market  is 
only  evidence  that  we  have  been  groping  about  for  some  powerful 
agent  which  will  instantly  kill  pathogenic  bacteria.  M.  J.  Rosenau^ 
of  the  U.  S.  Hygienic  Laboratories  most  forcibly  expressed  this  senti- 
ment when  he  said: 

"The  stress  of  modern  activities  demands  disinfecting  processes 
that  are  instantaneous  in  their  action,  all  pervading  in  their  effect, 
cheap,  harmless  and  free  from  any  unpleasant  odor.  Such  disinfec- 
tants are  unknown.  It  requires  time,  money,  and  the  expenditure 
of  well  directed  and  intelligent  energy  to  accomplish  satisfactory 
disinfection. 

"Until  recently  it  has  been  the  tendency  to  rely  too  largly  upon 
the  chemical  agents  for  the  destruction  of  bacteria,  and  to  ignore  in  a 
great  measure  the  natural  means  we  have  at  hand.  Fresh  air,  sunshine, 
cleanliness,  are  by  far  the  most  important  agents  for  destruction  of  bac- 
teria and  when  these  agents  are  brought  into  proper  use,  much  money 
will  be  saved  which  is  now  foolishly  wasted  upon  chemical  disinfectants. 
It  is  not  meant  by  the  foregoing  statement  that  chemical  disinfection  is 
entirely  without  virtue,  but  that  entirely  too  much  faith  has  been  put 
in  it  to  the  neglect  of  other  more  effective  natural  methods.  Proper 
disinfection  includes  the  use  of  sunlight,  fresh  air,  soap  and  water, 
liquid  and  gaseous  disinfectants  and  above  all,  it  implies  that  these 
agents  must  be  used  in  their  proper  strength  and  allowed  to  act  for  the 
proper  length  of  time.     '  Whatever  the  method  of  disinfection  adopted 

^  M.  J.  Rosenau:  Disinfectants.     Bulletin  of  Hygienic  Laboratory. 


INDUSTRIAL    HYGIENE  157 

or  wherever  it  may  be  done,  slip-shod  methods  can  result  in  nothing  but 
failure.  If  disinfection  is  worth  doing  at  all,  it  is  worth  doing  well. 
Careless  disinfection  is  worse  than  none  at  all.  The  fact  that  a  place 
has  been  disinfected  gives  the  occupant  a  sense  of  safety.  If  the  job 
has  been  done  incompletely  and  inefficiently,  this  sense  of  security  is 
unfounded  and  is  a  source  of  added  danger.'^ 

"  From  the  standpoint  of  the  industrial  physician  it  is  important  to 
know  what  methods  are  applicable  in  large  institutions.  It  is  the 
purpose  of  this  chapter  to  give  as  briefly  as  possible  the  most  accepted 
methods  of  disinfection  and  fumigation,  and  to  give  references  which 
may  help  the  reader  in  a  further  study  of  this  subject. 

"  For  practical  purposes  disinfecting  agents  maybe  divided  into  two 
classes,  physical  and  chemical.  The  physical  agents  are  sunlight, 
fresh  air,  cleanliness,  heat,  boiling  and  steam. 

"  Sunlight  and  fresh  air  are  of  great  value  and  wherever  possible  a 
conscientious  effort  should  be  made  to  allow  as  much  fresh  air  and  sun- 
light into  the  workrooms  as  possible.  This  may  be  especially  empha- 
sized in  the  case  of  toilet  rooms  which  are  too  often  tucked  into  some 
dark  corner,  where  fresh  air  and  sunlight  are  impossible.  Cleansing 
with  the  free  use  of  soap  and  water  and  scrub  brush  plays  an  ex- 
tremely important  role  in  the  disinfection  in  large  institutions.  It 
may  be  truly  said  that  much  more  cleaning  will  be  accomplished  if 
the  porters  are  given  soap  and  water  and  a  scrub  brush  and  told  to 
clean  than  when  they  are  given  a  strong  smelling  disinfecting  solution 
which  they  are  lead  to  believe  will  destroy  disease  germs  by  merely  mop- 
ping over  the  surface  of  the  given  article.  Heat  is  made  use  of  largely  by 
burning  contaminated  articles.  Boiling  may  be  used  for  such  articles 
as  will  not  stand  this  process  and  cannot  be  destroyed.  The  article 
to  be  disinfected  must  be  covered  by  boiling  water  for  at  least  twenty 
minutes.  Steam  under  pressure  is  a  very  effective  disinfectant  and 
is  frequently  used  in  the  disinfection  of  cuspidors  and  like  articles. 

"Chemical  disinfectants  are  divided  into  two  classes  (1)  gaseous, 
(2)  liquid. 

Gaseous  Disinfectants 

"  Of  these  formal dehyd  and  sulphur  are  of  the  greatest  value.  All 
crevices  must  be  tightly  sealed  and  kept  so  during  the  time  of 
fumigation. 

"In  using  formaldehyd,  it  is  important  that  a  sufficient  quantity 
be  used,  that  the  gas  be  evolved  rapidly,  that  the  temperature  of  the 
air  be  above  60°F.  if  possible,  and  its  humidity  at  least  60  per 
cent,  of  saturation.     Unless  the  atmospheric  conditions  are  naturally 

^  Disinfection — published  by  Illinois  State  Board  of  Health. 


158  INDUSTRIAL    MEDICINE    AND    SURGERY 

above  these  limitations,  the  defect  should  be  overcome  as  much  as 
possible  by  artificial  heat,  by  placing  shallow  vessels  of  boiling  water 
in  the  room,  by  sprinkling  formalin  on  the  floor  and  using  an  increased 
amount  of  formaldehyd." 

Three  methods  of  evolving  formaldehyd  gas  are  ordinarily 
available : 

1.  The  permanganate-formalin  method. 

2.  The  formalin-lime  and  alum-sulphate  method. 

3.  The  spraying  or  sheet  method. 

1.  Permanganate -formalin  Method.— Use  one  pint  of  formalin  and 
six  and  a  half  to  eight  ounces  of  permanganate  of  potash  crystals  for 
every  1000  cubic  feet.  Use  a  large  galvanized 'iron  or  tin  pail  or  can 
of  at  least  ten  quarts  capacity  for  each  pint  of  formalin. 

Place  the  permanganate  crystals  in  a  thin  even  layer  over  the 
bottom.  Place  the  pail  containing  the  crystals  in  a  pan  or  wash  tub 
containing  water,  placing  one  or  two  bricks  under  the  pail. 

Put  the  formalin  in  a  pail,  dipper,  pitcher  or  some  other  wide- 
mouthed  vessel  so  that  it  can  be  poured  quickly.  Pour  it  from  this 
over  the  crystals  and  depart.  Close  and  seal  the  door  of  exit.  This 
must  be  done  quickly  as  the  evolution  of  the  gas  is  very  rapid.  Allow 
the  room  to  remain  closed  for  at  least  eight  hours. 

If  the  space  to  be  fumigated  exceeds  1000  cubic  feet,  a  separate 
pail  should  be  used  for  each  pint  of  formalin  or  one  which  is  propor- 
tionately taller  to  prevent  the  mixture  from  sputtering  over  on  the 
floor. 

Some  slight  danger  from  fire  attends  this  process  and  it  should 
be  watched  through  a  window  during  the  few  minutes  necessary  for 
its  completion. 

The  present  high  price  of  permanganate  has  caused  this  process 
to  be  abandoned.  One  of  the  two  following  methods  should  be  used 
until  permanganate  again  approaches  its  former  price. 

2.  Formalin-lime  and  Aluminum  Sulphate  Method. — Dissolve 
four  (4)  ounces  of  aluminum  sulphate  in  one-half  pint  of  hot  water  and 
allow  the  solution  to  stand  for  a  few  hours.  Add  one  pint  of  formalin 
(35  to  40  per  cent.)  to  this  solution. 

Take  three  pounds  of  unslaked  lime  and  just  before  using  break 
into  small  pieces  and  place  in  a  pail  as  described  under  the  perman- 
ganate method.  The  lime  should  be  of  a  quality  that  will  slake  easily 
in  cold  water. 

Pour  the  formalin-aluminum  sulphate  mixture  over  the  lime  as 
described  in  the  permanganate  method. 

The  above  quantities  should  be  used  for  each  1000  cubic  feet 
of  air  space. 

The  time  of  exposure  should  be  eight  hours. 


INDUSTRIAL    HYGIENE  159 

3.  Spray  or  Sheet  Method. — This  method  is  efficient  under 
favorable  conditions  of  heat  and  moisture,  when  apphed  to  rooms  con- 
taining not  more  than  2000  cubic  feet.  Use  at  least  48  square  feet 
of  sheet  surface  for  each  pint  of  formalin  and  use  this  amount  for 
each  1000  cubic  feet  of  air  space.  The  ordinary  sheet  81  inches 
side  by  96  inches  long  has  an  area  of  54  square  feet.  This  is  a  good 
size  to  use. 

The  sheet  should  first  be  dampened,  so  that  the  formalin  will 
not  run  off  when  sprinkled  on.  However,  it  should  not  be  wet. 
Spread  each  sheet  over  cords  or  lines,  preferably  so  that  they  will  hang 
at  an  angle  of  45  degrees.  Pour  the  formalin  in  an  ordinary 
sprinkling  pot  and  pour  it  on  the  sheet  through  the  sprinkler.  Any 
other  spraying  device  may  be  used  if  more  convenient.  The  formalin 
does  not  damage  the  sheets.  The  temperature  of  the  room  must  be 
at  least  60°r.  or  this  method  is  not  effective.  Rooms  disinfected  by 
this  method  must  remain  closed  at  least  eight  hours.  By  using  a 
number  of  sheets  and  several  men  to  spray  on  the  formaldehyd  this 
method  has  been  found  very  useful  in  fumigating  departments  after 
contagious  cases  have  developed  therein. 

Sulphur  Dioxid. — Sulphur  dioxid  in  the  dry  state  has  practically 
no  disinfecting  power  but  in  the  presence  of  moisture  it  is  changed  into 
sulphurous  acid  gas  and  to  a  slight  extent  into  sulphuric  acid.  It  is 
these  acids  which  are  really  the  disinfecting  agents.  In  the  presence 
of  moisture  and  in  sufficient  concentration  it  is  effective  in  destroying 
disease  producing  germs  but  will  not  destroy  spores.  It  is  highly 
fatal  to  animal  life  and  is  especially  applicable  for  destroying  rats, 
flies,  fleas,  mosquitoes,  lice  and  other  vermin  which  may  carry  disease. 
It  is  much  used,  therefore,  for  disinfecting  holds  of  ships,  stables, 
barns,  warehouses,  freight  cars  and  structures  of  this  character. 

In  the  presence  of  moisture  it  attacks  most  metals  although  this 
can  be  prevented  by  spreading  vaselin  over  the  exposed  surfaces.  It 
bleaches  and  injures  cotton,  linen  and  woolen  fabrics,  curtains,  house- 
hold furnishings,  etc.  It  softens  paint  and  varnish  especially  if  they 
have  been  applied  recently.  It  injures  soap,  coffee,  tea,  flour,  sugar, 
matches,  rice,  etc.,  when  they  are  freely  exposed  to  it.  It  will  also 
discolor  wall  paper  and  bleaches  all  vegetable  and  many  anilin  colors. 
The  above  mentioned  ill  effects  only  occur  in  the  presence  of  moisture. 
Moisture,  while  essential  to  its  action  as  a  disinfectant,  is  not  necessary 
when  it  is  applied  for  the  purpose  of  killing  rats,  insects  or  vermin. 

Two  methods  of  using  sulphur  dioxid  are  commonly  used :  (1)  the 
pot  method  and  (2)  the  liquid  sulphur  dioxid  method,  the  latter  being 
about  ten  times  more  expensive. 

Owing  to  the  fact  that  sulphur  dioxid  is  rarely  used  for  fumigating 
in  industrial  institutions,  these  methods  will  not  be  given  in  detail. 


160  INDUSTRIAL   MEDICINE    AND    SURGERY 

Liquid  Disinfectants 

There  is  a  great  variety  of  liquid  disinfectants  upon  the  market, 
some  of  which  are  useful  but  many  of  which  are  worthless.  In  the  use 
of  these  chemical  disinfectants  there  has  been  a  great  economic  waste 
which  in  a  large  measure  can  be  replaced  by  the  use  of  soap  and  water. 
If,  however,  a  chemical  disinfectant  is  thought  advisable  only  those 
should  be  used  which  have  been  thoroughly  tested  not  only  by  labora- 
tory but  also  by  practical  methods.  In  1912  Thomas  B.  McClintic,^ 
Public  Health  and  Marine  Hospital  Service  of  the  United  States, 
conducted  a  very  elaborate  series  of  tests  on  various  disinfectant 
solutions,  and  it  is  interesting  to  note  that  he  found  a  large  per  cent,  of 
the  widely  advertised  disinfectants  to  be  practically  worthless.  It 
is  his  conclusion  that  liquor  cresolis  compositus,  U.  S.  P.,  is  an  excel- 
lent disinfectant  from  the  standpoint  of  both  efficiency  and  econ- 
omy. It  has  a  phenol  coefficient  of  3,  and  can  be  prepared  on  a 
large  scale  for  about  50  cents  per  gallon  Of  course,  the  cost  varies 
greatly  with  the  scale  upon  which  it  is  prepared.  By  the  barrel, 
linseed  oil  and  cresol  can  be  obtained  at  about  80  cents  and  50 
cents  per  gallon,  respectively.  The  commercial  potassium  hydroxid 
can  be  bought  for  a  few  cents  per  pound,  or  potash  lye  can  be  used  in 
its  stead.  According  to  the  United  States  Pharmacopeia  liquor  cresolis 
compositus  (compound  solution  of  cresol)  is  prepared  as  follows : 

Grams 

Cresol 500 

Linseed  oil 350 

Potassium  hydroxid '. 80 

Water,  a  sufficient  quantity  to  make 1000 

Dissolve  the  potassium  hydroxid  in  50  grams  of  water  in  a  tarred 
dish,  add  the  linseed  oil,  and  mix  thoroughly.  Then  add  the  cresol, 
and  stir  until  a  clear  solution  is  produced;  and,  finally,  add  water 
sufficient  to  make  the  finished  product  weigh  1000  grams. 

For  the  sake  of  completeness  a  few  other  liquid  disinfectants  may 
be  mentioned. 

Formalin — the  35  to  40  per  cent,  solution  of  formaldehyd  gas — is  a 
very  efficient  disinfectant,  its  great  drawback  being  the  irritation 
caused  by  the  liberated  gas.  For  this  reason,  it  is  not  adapted  to 
washing  floors  or  walls  although  smaller  surfaces  may  be  satisfactorily 
treated  with  it.  Formalin  is  not  corrosive.  Fabrics  and  other  arti- 
cles, except  leathers,  furs,  and  skins,  are  not  usually  injured  by  it.  It 
is  a  good  deodorant  and  is  not  apt  to  cause  accidental  poisoning.     Its 

^Thomas  B.  McCIintic  and  John  T.  Anderson:  1.  Methods  of  Standardizing 
Disinfectants.  2.  The  Determination  of  the  Phenol  Coefficient  of  some  com- 
mercial disinfectants.     Hygienic  Laboratory  Bulletin  No.  82,  1912. 


INDUSTRIAL    HYGIENE  161 

action  is  not  retarded  by  albuminous  matter  and  it  is  well  adapted  to 
the  disinfection  of  urine,  stools,  sputum  and  other  similar  discharges. 
It  will  deodorize  fecal  matter  almost  instantly.  A  small  quantity  of 
pure  or  diluted  formalin  poured  into  water  closet  bowls,  urinals,  etc. 
will  destroy  offensive  odors. 

Carbolic  Acid. — This  is  a  useful  disinfectant  when  used  in  a  strength 
of  at  least  3  to  5  per  cent,  solution.  In  these  strengths  it  is  not  des- 
tructive to  fabrics,  colors,  metals,  etc.  It  does  not  actively  coagulate 
albumin  and  is  therefore  useful  for  the  disinfection  of  bed  linen,  soiled 
clothes,  stools,  sputum,  etc. 

For  disinfecting  sputum,  stools,  etc.  a  5  per  cent,  solution  is 
added  to  an  equal  volume  of  the  excretion,  the  mass  then  thoroughly 
mixed  and  allowed  to  stand  for  an  hour  before  final  disposal. 

The  Cresols. — The  vast  majority  of  the  disinfectants  sold  to  the 
public  are  mixtures  of  cresols  (carbolic  acid  like  substances)  and  soap, 
together  with  other  inert  tar  oils,  etc.  Unless  these  disinfectants 
have  a  guaranteed  phenol  coefficient  they  should  not  be  considered. 

Bichlorid  of  Mercury. — This  is  a  very  powerful  disinfectant  when 
applied  in  sufficient  strength  to  non-metallic  and  non-albuminous 
matter.  It  is  highly  corrosive  and  therefore  is  limited  in  its  usage. 
The  solutions  usually  used  are  of  a  strength  of  one  part  in  1000,  or 
one  part  in  500  of  water. 

Lim.e. — ^Lime  in  certain  of  its  forms  is  one  of  the  best  and  cheapest 
of  disinfectants  and  should  be  much  more  commonly  used,  especially 
for  the  disinfection  of  stools.  It  may  be  used  either  as  quicklime  or 
as  freshly  slaked  lime  in  the  form  of  whitewash  or  milk  of  lime. 

1.  Quicklime  (calcium  oxid),  a  very  caustic  substance,  suitable  to 
destroy  any  organic  matter,  is  often  used  as  a  disinfectant. 

2.  Whitewash  is  simply  a  thin  mixture  of  slaked  lime  with  a  little 
glue  added  to  make  it  stick  to  the  surface  to  which  it  is  applied.  Its 
uses  are  well  known. 

3.  Milk  of  lime  is  prepared  by  mixing  slaked  lime  with  about  four 
times  its  volume  of  water.  Freshly  slaked  lime  must  be  used  and  the 
mixture  itself  is  of  no  value  as  a  disinfectant  after  three  or  four  days. 
It  is  very  useful  as  a  disinfectant  for  stools. 

4.  Chlorinated  lime  (hypochlorite  of  lime,  ''chlorid  of  lime," 
" hypochlorid, "  "bleaching  powder"),  when  in  a  fresh  condition, 
is  a  very  effective  disinfectant.  For  disinfecting  stools  and  other 
organic  matter,  it  may  be  used  in  a  5  per  cent,  solution  or  the 
dry  powder  may  be  added  to  the  substance  to  be  disinfected  in  an 
amount  sufficient  to  make  a  5  per  cent,  mixture.  The  mixture  must 
be  thorough'. 

A  mixture  of  six  ounces  of  chlorinated  lime  to  the  gallon  of  water 
is  largely  used  for  scrubbing  floors  and  other  surfaces. 
11 


162  INDUSTRIAL    MEDICINE    AND    SURGERY 

Of  recent  years  chlorinated  lime  or  "hypochlorite"  has  been  ex- 
tensively used  for  disinfecting  drinking  water. 

Proper  Disinfection  of  Cuspidors 

Proper  disinfection  of  cuspidors  has  been  one  of  the  hardest  prob- 
lems with  which  we  have  had  to  cope.  This  problem  is  handled  in 
a  great  variety  of  ways,  from  the  use  of  the  old  sawdust  boxes  to 
the  excellent  system  devised  by  Wm.  J.  Manning  of  the  U.  S.  Print- 
ing Department.  Any  method  of  disinfection  which  falls  short  of 
sterilization  by  boiling  or  steam,  or  the  complete  destruction  of 
the  cuspidor  by  burning  is  merely  a  method  of  cleaning  and  can, 
therefore,  be  done  just  as  thoroughly  with  soap  and  water  as  by  the 
use  of  some  high  priced  disinfectant  solution.  However,  after  a  thor- 
ough cleansing  it  is  advisable  to  add  some  liquid  disinfectant  such  as 
a  5  per  cent,  of  liquor  creosote  compound  solution,  in  order  that  the 
disinfectant  may  act  immediately  and  for  a  long  time  on  the  contami- 
nated substance.  The  ideal  method  described  by  Wm.  J.  Manning^ 
consists  in  having  metal  cuspidors  which  can  be  picked  up  by  a  special 
handle  and  conveyed  by  a  special  truck  to  a  sterilization  room.  The 
cuspidors  are  emptied  and  washed  out  with  hot  water,  and  then  ex- 
posed to  a  jet  of  steam  for  five  to  ten  minutes. 

This  method  has  for  its  great  advantage  the  absolute  sterilization 
of  the  cuspidor  and  the  fact  that  it  is  not  necessary  for  the  porters  to 
touch  the  cuspidor  at  any  time  during  the  cleaning  process. 

Drinking  Fountains 

It  should  be  one  of  the  duties  of  the  industrial  physician  to  make 
frequent  bacteriologic  examinations  of  the  source  of  water  supply  as 
well  as  to  investigate  the  drinking  cups  or  drinking  fountains.  Of 
recent  years  we  have  been  placing  considerable  faith  in  the  safety  of 
ordinary  drinking  fountains.  The  fact  that  drinking  fountains  may 
be  a  source  of  contamination  was  demonstrated  by  Pettibone,  Borgorl, 
and  Clark, 2  University  of  Wisconsin,  who  were  able  to  definitely  prove 
that  the  drinking  fountains  of  that  institution  were  the  source  of  con- 
tamination in  the  spreading  of  a  grippe  epidemic.  Fifty-eight  per 
cent,  of  the  cultures  taken  from  their  drinking  fountains  during  the 
epidemic  showed  positive  cultures.  Similar  work  has  been  done  by 
other  investigators  with  like  results.  Their  remedy  for  this  source  of 
infection  was  to  have  a  drinking  fountain  from  which  the  water  was 
ejected  from  a  pipe  at  an  angle  of  15  degrees,  thus  preventing  lip 
contact  as  well  as  droplet  infection. 

1  William  J.  Manning:  United  States  Printing  Department. 

2  Pettibone,  Borgorl,  Clark:  Journal  Bact.,  1916,  1,  471. 


INDUSTRIAL    HYGIENE  163 

Washing  Facilities 

Every  employer  should  provide  adequate  sanitary  washing 
facilities  for  his  working  force.  Showers  and  bathing  facilities  should 
be  included  when  the  work  involves  contact  with  poisonous  material. 

The  installation  of  stationary  wash  bowls  with  the  common  soap 
and  common  towel  adjuncts  so  commonly  seen  in  many  industries 
has  been  responsible  for  much  disease  contamination.  It  is  not  at  all 
uncommon  to  see  an  employee  spit  or  blow  his  nose  in  one  of  these 
wash  basins  and  then  turn  to  the  common  roller  towel  and  wipe  his 
nose  on  this.  Consider  the  ease  with  which  disease  could  spread  to  the 
next  employee  who  uses  these ! 

Many  states  have  legislated  against  the  common  towel  but  have 
neglected  precautions  with  regard  to  the  common  wash  basin  and  soap. 

The  following  quotation  from  the  Standards  of  the  Federal  Em- 
ployees Compensation  Commission  shows  what  should  be  done  in 
every  industry  concerning  washing  facilities  and  lockers: 

"Provision  of  Individual  Wash  Basin  or  Trough. — No  wash  basins 
or  troughs  for  common  use  should  be  installed.  Facilities  for  washing 
hands  and  face  should  be  such  that  employees  must  necessarily  wash 
from  the  flowing  stream. 

Note. — ^The  wash  basin  with  stopper  is  unsanitary.  This  requirement  is 
designed  to  prevent  the  transmission  of  disease  through  the  common  use  of  a 
washing  fixture  made  to  contain  water. 

"  Spacing  of  Fixtures. — Fixtures  for'  washing  the  hands  and  face 
should  be  spaced  not  less  than  24  inches  center  to  center  so  that  a  man 
can  wash  without  splashing  his  neighbor. 

"Number  of  Faucets. — The  number  of  faucets  for  washing  hands 
and  face  should  be  not  less  than  one  to  every  6  employees,  based  upon 
the  maximum  number  employed  on  any  one  shift  in  the  departments 
using  the  equipment.  Regular  showers  (see  Sec.  7)  may  be  substituted 
in  part  for  these  faucets. 

"  Temperature  Control. — (a)  Both  hot  and  cold  water  feeding  into  a 
common  spigot  should  be  provided  for  each  fixture  and  provision  made 
for  temperature  control. 

'  (6)  Wherever  practicable,  automatic  thermostatic  control  should 
be  installed  in  the  main  supply  pipe  to  positively  limit  the  maximum 
temperature  to  125°F. 

"Clothes  Hooks. — An  adequate  number  of  clothes  hooks  shall  be 
provided. 

"Soap  Holders. — Proper  holders  for  soap  shall  be  provided. 
Showers. — The  number  of  showers  should  not  be  less  than  one  to 
every   twenty-five  employees,  based  upon  the  maximum  number  of 
employed  on  any  one  shift  in  the  departments  using  the  equipment. 


164  INDUSTRIAL   MEDICINE    AND    SURGERY 

"  This  proportion  may  be  varied  according  to  the  character  of  the 
work. 

'^Showers  to  be  Separated. — The  showers  should  be  separated  by 
partitions  in  order  to  encourage  men  to  use  the  shower  who  would  not 
otherwise  do  so;  and  to  prevent  the  user  splashing  his  neighbor. 

"Finish  of  Walls. — The  enclosure  should  be  finished  in  a  light  color 
to  give  a  neat  appearance  and  facilitate  cleaning  (see  also  Sec.  3). 

"Hot  and  Cold  Water. — (a)  Showers  should  have  hot  and  cold 
water  and  be  equipped  with  a  hot  and  cold  regulating  valve. 

Note. — The  system  should  be  arranged  to  prevent  scalding.  This  does  not 
necessarily  imply  the  need  of  a  thermostatic  control  for  each  shower  in  a  battery 
of  showers.  Where  such  automatic  control  is  necessary  it  can  ordinarily  be 
attached  to  the  heater. 

"(6)  A  regulating  device  should  be  so  located  that  it  can  be 
operated  without  standing  under  the  shower. 

"Location  of  Supply  Pipes. — Supply  pipes  to  showers  should  be 
placed  overhead  to  avoid  the  possibility  of  a  person  coming  in  con- 
tact with  the  hot  pipes,  and  to  facilitate  the  cleaning  of  the  shower 
enclosures. 

Lockers  and  Dressing  Rooms. 

"Number. — A  locker  or  other  method  for  caring  for  change  of 
clothing,  etc.,  should  be  provided  for  each  employee. 

"Clothes  lockers  should  be  located  in  buildings  or  enclosures  used 
in  conjunction  with  washing  facilities. 

"  Material  for  Lockers. — ^Lockers  should  be  of  steel  and  have  proper 
ventilation.  They  should  be  at  least  4  inches  off  the  floor,  to  facili- 
tate cleaning  without  contaminating  the  locker. 

"  Size  of  Lockers. — The  size  of  the  lockers  should  be  not  less  than 
12  inches  by  15  inches  floor  space  and  of  sufficient  height  to  provide 
at  least  5  feet  clear  height ;  where  not  set  in  wall  they  shall  have  gabled 
tops  to  prevent  accumulation  of  rubbish  and  other  materials." 

Toilets 

Again  quoting  from  the  Employees  Compensation  Commission,  we 
find  the  following  recommendations: 

"  Number  of  Installations  of  Toilets. — There  should  be  a  number 
of  small  installations  rather  than  a  few  large  ones. 

Note. — This  is  recommended  so  that  available  space  in  shops  and  yards  may  be 
utilized.  If  closets  are  conveniently  located  there  will  be  less  time  lost  and 
employees  will  be  relieved  promptly,  which  promotes  good  physical  condition. 

"Number  of  Toilets.- — The  number  of  seats  should  be  not  less  than 
one  to  every  15  persons,  based  upon  the  maximum  number  of  em- 
ployees in  any  one  shift  in  the  department  using  the  unit. 


INDUSTRIAL    HYGIENE  165 

"Specifications  for  Closets.^ — (a)  Closets  should  be  of  individual 
bowl  type  with  individual  water  seal  and  should  be  made  of  porcelain 
or  vitreous  china,  and  not  of  enameled  iron. 

Note. — Flush  range  closets  are  considered  unsanitary  and  similar  to  an  open 
sewer  and  shall  not  be  used.  Enameled  iron,  of  which  the  ranges  are  most  com- 
monly made  soon  corrodes,  leaving  the  equipment  in  a  deplorable  condition. 
Flushing  feces  under  others  using  the  range  is  unsanitary,  disagreeable,  and  objec- 
tionable. Individual  closets  made  of  porcelain  or  vitreous  china  overcome  the 
objectionable  features  and  provide  a  sanitary,  durable,  neat  appearing  bowl,  which 
can  be  thoroughly  cleaned. 

"(b)  The  seat  of  each  water  closet  should  be  made  of  wood  or  other 
non-heat  absorbing  material,  coated  with  varnish  or  other  finish 
which  will  make  it  impervious  to  water.  Under  no  circumstances 
should  the  use  of  seats  made  of  enameled  ironware,  procelain  or  other 
similar  heat  absorbing  materials  be  allowed. 

Note. — The  use  of  non-heat  absorbing  material  for  seats  ehminates  any 
harmful  effects  which  might  come  from  men  sitting  on  a  cold  surface. 

"  (c)  The  size  of  the  opening  should  be  at  least  7  inches  in  width 
and  11  inches  in  length. 

Note. — This  size  is  recommended  to  insure  the  maintenance  of  a  clean  seat. 

"Specifications  for  Privies. — (a)  The  hole  in  the  seat  should  be 
of  the  same  size  as  specified  in  rule  52  (c). 

"(h)  There  should  be  a  close-fitting  cover  for  each  hole. 

Note. — Persons  using  the  closet  should  be  encouraged  to  keep  the  seat  covered 
to  prevent  flies  and  other  germ  carrying  insects  coming  in  contact  with  the  feces. 

"Provision  of  Washing  Faucets  in  Toilet  Rooms. — Unless  wash  rooms 
are  in  close  proximity  to  the  closet,  each  closet  room  should  be  supplied 
with  at  least  one  washing  faucet. 

Note. — The  installation  of  a  washing  faucet  in  a  closet  room,  not  in  close 
proximity  to  a  wash  room,  is  to  promote  personal  cleanliness  by  encouraging  men 
to  wash  after  using  these  facilities. 

Number  of  Urinals. — An  adequate  number  of  separate  urinals 
should  be  placed  throughout  shops  and  yards  located  conveniently 
to  the  place  where  men  work.  An  adequate  number  shall  also  be 
installed  in  each  toilet  room.  The  total  number  should  be  approxi- 
mately 1  to  every  30  employees. 

Note. — This  will  avoid  loss  of  time  required  for  a  man  to  walk  some  distance 
and  will  tend  to  avoid  violation  of  sanitary  rules.  At  least  one  urinal  should  be 
installed  in  each  toilet  room  to  discourage  the  unsanitary  practice  of  using  closets 
as  urinals. 

Specifications  for  Urinals. — (a)  Troughs  and  basins  shall  not  be 
used  for  urinals.     The  wall  or  vertical  slab  urinal  with  proper  flushing 


166  INDUSTRIAL    MEDICINE    AND    SURGERY 

should  be  used  preferably  to  the  porcelain  stall.  The  floor  in  frojit  of 
urinal  must  slope  toward  the  drain." 

The  U.  S.  Department  of  Labor,  the  Committee  on  Labor  of  the 
Council  of  National  Defense,  and  the  New  York,  Pennsylvania, 
Ohio  and  Massachusetts  Departments  of  Industry  and  Labor,  as  well 
as  a  few  of  the  other  states,  have  studied  the  problems  of  illumination, 
ventilation,  fatigue  and  similar  problems  of  industrial  hygiene.  The 
physician  in  industry  is  advised  to  obtain  the  bulletins  published  by 
these  various  agencies  in  order  to  gain  a  broad  knowledge  concerning 
these  technical  problems.  A  complete  set  of  the  bulletins  prepared 
by  the  Council  of  National  Defense  can  be  secured  by  writing  to  the 
Bureau  of  Statistics,  of  the  U.  S.  Department  of  Labor. 

Recently  the  United  States  Public  Health  Service  has  made  some 
thorough  investigations  of  these  subjects  and  their  literature  can  like- 
wise be  obtained  by  writing  to  them. 

The  Committee  on  Hazardous  Occupations  for  Women  in  Industry 
has  prepared  standards  of  sanitation  which  are  especially  applicable 
to  this  sex.  These  can  also  be  secured  from  the  Department  of 
Labor. 

It  is  exceedingly  encouraging  that  the  National  Government  is 
taking  this  great  interest  in  industrial  hygiene.  Our  country  has 
lagged  behind  other  governments  in  meeting  these  problems.  Such 
an  interest  now  bespeaks  the  approach  of  a  real  national  health  policy. 


CHAPTER  XVII  ^ 

INDUSTRIAL  HYGIENE  AND  PRODUCTION 

The  World  War  has  focused  attention  upon  Production.  People 
who  have  given  little  thought  to  this  problem  in  the  past  are  now  con- 
sidering their  responsibility  toward  producing  the  essentials,  or  to- 
ward conserving  those  things  produced,  necessary  to  the  winning  of 
the  war. 

Our  allies  have  been  solving  this  problem  for  four  years  and  as  a 
result  have  made  changes  in  their  industrial  life  which  are  revolution- 
ary. Our  own  nation,  for  more  than  a  year  now,  has  been  struggling 
with  the  same  problem.  No  country  has  ever  before  been  called  upon 
to  make  such  gigantic  efforts  and  no  country  has  ever  succeeded  in 
securing  greater  results  in  so  short  a  time.  But  the  cost  has  been  ter- 
rific both  financially  and  from  the  standpoint  of  wasted  energy,  and 
even  of  human  life. 

Our  government,  with  the  master  minds  in  control,  and  the  whole- 
hearted, determined  support  of  its  people,  has  accomplished  in  a  little 
more  than  a  year  what  seemed  the  impossible.  No  criticisms,  however 
valid,  can  overshadow  the  glory  of  this  accomplishment.  In  the 
state  of  our  unpreparedness  it  was  only  to  be  expected  that  excessive 
outlays  of  money,  of  energy  and  of  human  life  would  be  necessary  to 
meet  this  emergency. 

During  the  short  period  that  we  have  been  in  the  war  the  world 
has  seen  a  great  army  mobilized  and  thrown  into  the  struggle — over  a 
million  and  a  half  men  already  in  Europe.  It  has  seen  a  great  emer- 
gency ship  building  program  put  into  motion  with  an  ever  increasing 
number  of  ships  being  launched  to  carry  this  army  and  their  needed 
supplies  across  the  seas.  Ordnance,  munitions,  quartermaster  supplies, 
hospital  supplies,  locomotives,  trucks,  wagons,  automobiles,  gas 
offensive  and  gas  defensive  supplies,  food  and  the  other  daily  necessi- 
ties of  life  for  both  men  and  animals,  have  been  produced  and  trans- 
ported in  quantities  heretofore  unheard  of.  Even  aeroplanes  finally 
are  being  produced  in  great  numbers.  And  in  France  the  world  has 
seen  unbelievable  feats  of  engineering  performed.  Great  docks,  for 
the  receiving  of  these  supplies,  will  remain  after  the  war  as  part  pay- 
ment of  our  debt  to  heroic  France  and  as  a  monument  to  our  efforts. 
Great  railway  systems  have  been  built  meeting  the  problems  of  war 

167 


168  INDUSTRIAL   MEDICINE    AND    SURGERY 

transportation  now,  and  standing  as  a  promise  of  the  part  which  we 
must  play  in  the  rehabihtation  of  that  country  after  the  war. 

No  true  American  lives  whose  heart  does  not  swell  with  pride  when 
he  contemplates  the  accomplishments  of  his  country  during  this  last 
year.  And  with  true  American  spirit  we  have  paid  the  price,  and  will 
continue  to  pay  it  without  a  murmur  even  though  it  is  a  hundred 
times  as  great. 

All  this  the  world  has  seen.  But  only  a  few  see  or  realize  the  great 
efforts  that  are  simultaneously  being  made  by  our  government  to 
conserve  its  man  power,  to  utilize  its  human  energy  in  the  most  eco- 
nomic manner  and  to  reduce  the  cost  of  this  mammoth  ilndertaking 
to  a  minimum. 

At  the  beginning  of  the  war  "business  as  usual"  was  felt  to  be  a 
prime  essential.  It  was  realized  that  speeding-up  of  existing  machin- 
ery and  the  creation  of  much  new  machinery  would  be  necessary, 
but  the  economic  and  social  existence  of  our  country  would  be  dis- 
turbed the  least  if  this  principle  of  "business  as  usual"  could  be 
maintained. 

Gradually  these  business  methods  of  the  country  are  being  revo- 
lutionized. Non-essential  business  is  being  curtailed  and  the  em- 
ployees are  being  diverted  to  essential  production.  The  employers 
of  the  country  are  readjusting  wages,  and  hours  of  labor,  and  are 
beginning  to  recognize  that  improved  working  conditions  are  necessary 
for  maximum  production.  Many  corrections  have  already  been  made. 
The  labor  unions  are  making  concessions  permitting  of  open  shop 
methods,  employment  of  women  and  arbitration  policies  which  will 
do  away  with  strikes.  You  can  call  it  "business  as  usual"  if  you  wish, 
but  already  we  have  a  vision  of  those  changes  in  industry  which  before 
the  war  were  called  the  "dreams  of  idealists." 

Changes  are  likewise  taking  place  in  the  government.  The  exist- 
ing governmental  agencies  were  depended  upon  to  do  most  of  the  war 
work,  but  to  assist  them  numerous  advisory  committees  were  formed. 
That  these  committees,  advisory  in  character  but  with  no  executive 
powers,  were  useful  there  is  no  gainsaying.  But  their  greatest  useful- 
ness was  the  part  which  they  have  played  in  the  transition  of  our  peace 
time  government.  Slowly  but  surely  we  have  seen  these  advisory 
committees  replaced  by  executive  boards  and  in  turn  these  boards 
replaced  by  individuals  who  have  the  power  to  perfect,  and  are  held 
responsible,  for  some  definite  part  of  this  great  war  program. 

Gradually  the  federal  government  has  taken  over  more  and  more  of 
the  time  honored  rights  of  the  states.  And  gradually  the  work  of 
departments  and  bureaus  has  been  centralized  and  unified.  This  has 
resulted  in  increased  production  with  decreased  cost  chiefly  by  doing 
away  with  duplication  of  effort  in  the  different  departments.     The 


INDUSTRIAL    HYGIENE    AND    PRODUCTION  169 

executive  powers  given  by  the  Overman  bill  to  our  President  have 
even  greater  functions  than  have  as  yet  been  revealed.  The  lubri- 
cation represented  by  doing  away  with  interdepartmental  jealousies, 
and  the  labor  saving  devices,  represented  by  doing  away  with  duplica- 
tion of  effort,  have  already  given  the  country  a  smoother  running  ma- 
chine with  increased  production. 

No  thinking  man  of  to-day  will  deny  that  these  changes  in  our  social 
and  economic  existence,  and  these  changes  in  the  government  itself, 
taking  place  because  of  war  conditions,  are  here  to  stay. 

No  truer  words  were  ever  spoken  than  those  of  President  Wilson 
when  he  said  that  this  was  a  "War  to  make  the  world  safe  for  Democ- 
racy."    The  victory  over  militarism  and  the  autocracy  of  the  Central 
Powers  will  not  equal  the  victory  over  the  tyranny  and  autocratic 
practices  that  have  marked  class  distinction  in  all  countries. 

In  the  beginning  this  was  a  war  against  the  efforts  of  Germany  for 
the  accession  of  more  territory.  Then  it  became  a  war  for  democracy. 
And  now  it  is  a  war  for  social  democracy.  The  need  of  maximum 
production  to  wage  this  war  is  the  weapon  which  is  gaining  this  victory 
for  a  true  democracy.  " 

Our  Allies  found  that  under  the  old  relationships  existing  between 
employer  and  laborer  maximum  production  could  not  be  maintained. 
Changes  were  necessary  and  changes  were  made.  These  changes 
represent  the  getting  together  of  labor  and  industry  and  the  mutual 
adjustment  of  conditions.  Labor  could  not  force  its  contentions  on 
industry.  Neither  could  industry  force  labor  to  accept  its  views.  The 
government  could  not  arbitrarily  decide  for  one  or  the  other.  But 
by  conferences,  by  sacrificing  radical  principles  on  both  sides,  and  by 
concessions  on  the  part  of  the  governments,  whereby  they  assumed 
a  share  of  certain  losses  to  both,  the  new  era  of  true  democracy  has 
been  inaugurated. 

In  England  shorter  hours  of  labor  have  been  established  and 
careful  studies  reveal  the  fact  that  this  has  increased  production. 
Wages  have  been  increased,  working  conditions  have  been  improved, 
protection  against  disease  and  accident  hazards  has  been  established 
and  thousands  of  homes  for  employees  have  been  built  where  better 
living  conditions  can  be  maintained — all  of  these  have  played  a  decided 
part  in  increasing  production.  The  labor  class  of  England  has  asked 
"If  these  things  are  essential  for  increasing  production  for  war  purposes, 
then  why  are  they  not  quite  as  essential  for  increasing  production  in 
peace  times?"  And  invariably  the  answer  from  all  classes  has  been 
that  these  things  are  essential  and  must  carry  on  after  the  war. 

In  our  own  land  of  freedom  the  "exploitation  of  labor"  has  been 
known,  even  the  exploitation  of  woman  and  child  labor.  Before  the 
war  conditions  were  changing  but  it  was  a  very  slow  process.     With 


170 


INDUSTRIAL    MEDICINE    AND    SURGERY 


the  war  this  demand  for  production  is  bound  to  force  these  changes 
within  the  year. 

The  sacrifice  of  blood  which  we  are  making  will  bring  its  blessings 
in  the  forna  of  these  by-products  of  war- — ^by-products  which  will  mean 
a  greater  victory  than  merely  overwhelming  our  enemy.  Let  us  hope 
that  if  an  early  peace  should  come  the  country  will  nevertheless  learn 
these  lessons. 

During  the  decade  before  the  war  our  great  industries  in  the  United 
States  made  their  greatest  strides  in  efficiency.     Better  relationship 


Fig.  35.- 


-Model  munition   factory  in   England.     Here   women   of   all    classes,   under 
sanitary  surroundings,  are  helping  win  this  war. 


between  labor  and  the  employer  had  been  established.  Wages  and 
hours  of  work  were  better  and  more  nearly  uniform.  The  problems  of 
labor  turn-over,  of  hiring  and  firing  and  of  unemployment  had  received 
more  careful  and  more  intelligent  consideration.  Better  social  con- 
ditions for  the  worker  and  his  family  were  being  recognized  as  an 
efficiency  measure.  The  problem  of  the  effect  of  alcohol  on  our 
industrial  life  was  being  met.  Protection  from  occupational  hazards 
and  from  accidents  had  been  carefully  studied  and  methods  standard- 
ized. Experts  in  Industrial  Engineering  were  being  educated  and 
turned  out  in  ever  increasing  numbers. 

Above  all  the  principles  of  industrial  hygiene  had  been  evolved  and 
were  already  installed  in  many  concerns.     Physicians,  highly  trained 


INDUSTRIAL   HYGIENE    AND    PRODUCTION  171 

and  reputable,  were  more  and  more  entering  the  field  of  industrial 
medicine  and  surgery. 

Thus,  without  knowing  it  the  nation  was  undergoing  a  state  of 
preparedness.  And  during  these  days  when  maximum  production  is 
the  cry  of  the  hour  the  influence  of  all  this  work  is  being  felt.  The 
principles  of  industrial  hygiene  are  now  recognized  as  the  very  founda- 
tion of  maximum  production. 

During  the  first  year  of  the  war  the  speeding-up,  the  forming  of 
new  industries,  and  the  great  demand  on  the  old,  threw  labor  and 
industrial  conditions  into  a  frightful  state.  The  housing  conditions 
for  employees  in  many  centers  were  soon  overtaxed  and  became 
intolerable.  Beds  were  used  day  and  night  in  three  shifts.  Sanitary 
conditions  deteriorated  rapidly  due  to  the  increased  demands  on  water- 
supplies,  sewage  systems,  etc.  Shops  were  overcrowded.  The  food 
supply  was  inadequate  and  profiteering  became  rampant.  Men  from 
nearby  towns  flocked  to  industrial  centers  to  work  and  lost  time  and 
forfeited  wages  because  of  transportation  conditions. 

The  percentage  of  labor  turn-over  increased  to  over  1000  per  cent, 
in  some  cases.  Employees,  discontented  with  the  above  conditions 
and  influenced  by  the  promise  of  higher  wages  from  other  concerns, 
would  leave  their  jobs  without  notice.  Two  concerns,  equally  neces- 
sary to  war  production,  would  influence  employees  to  leave  one  or  the 
other. 

These  conditions  in  the  industries  and  homes  added  greatly  to 
the  sick-rate.  The  floating  labor  was  a  means  of  spreading  diseases. 
"Green  hands"  added  to  the  accident  rate  to  a  very  marked  degree. 
The  lack  of  any  effort  to  select  men  for  proper  work  according  to  physi- 
cal qualifications  added  to  the  inefficiency  of  the  working  forces.  The 
lack  of  precautions  against  occupational  disease  in  our  munition  fac- 
tories added  to  the  toll  of  war  victims.  The  wonder  is  that  production 
attained  its  present  proportions. 

But  during  this  period  many  different  agencies  of  the  government 
were  at  work  to  correct  these  conditions.  The  National  Defense 
Council  through  its  sections  on  Labor  and  on  Medicine  early  drew  up 
standards  on  many  important  industrial  hygiene  methods  and  cir- 
culated these  freely.  As  it  was  only  an  advisory  body  however,  it 
could  not  enforce  these  methods.  The  Women's  Committee  of  the 
National  Defense  Council,  "Department  of  Women  in  Industry," 
the  Women's  Division  of  the  Department  of  Labor,  the  Women's 
Division  of  the  Ordnance  Department,  and  the  various  women's  divi- 
sions of  the  State  Defense  Councils  have  all  contributed  studies  and 
recommendations  tending  to  improve  conditions  for  women  in  industry. 
All  such  improvements  will  naturally  better  working  conditions  for 
both  men  and  women.     The  great  drawback  to  all  these  committees 


172  INDUSTRIAL    MEDICINE    AND    SURGERY 

was  that  they  had  advisory  functions  only.  During  the  last  few 
months  three  important  groups  have  been  designated  by  the  Federal 
government  to  correct  these  industrial  conditions.  Their  work  is 
bound  to  speed  up  production.  All  of  these  have  a  direct  bearing 
on  industrial  hygiene.  In  fact  the  surgeon  familiar  with  industrial 
practices  is  represented  in  each  group. 

Without  discussing  the  other  functions  of  these  bodies  we  will 
consider  here  only  those  functions  which  have  a  direct  bearing  on  in-  ' 
dustrial  hygiene  and  its  relation  to  production. 

Early  in  the  present  year  the  Department  of  Labor  underwent  a 
reorganization.  It  formed  its  bureau  of  War  Labor  Administration 
and  took  specialists  from  all  over  the  country  and  placed  them  as 
Chiefs  of  Divisions.  These  men  and  women  are  responsible  for  the 
administration  and  results  of  their  divisions.  Already  the  labor  sup- 
ply is  being  controhed  and  dealt  out  and  shifted  according  to  priority 
importance.  Large  groups  of  field  workers  have  been  formed  to  study 
industrial  and  labor  conditions  throughout  the  country.  The  work  of 
other  sections  and  committees  is  being  co-ordinated  and  there  is  less 
duplication  of  effort.  It  is  to  be  hoped  that  all  committees  working 
on  labor  problems  will  be  forced  to  do  so  under  a  general  plan  outlined 
by  this  Labor  Administration.  The  executive  powers  of  this  Labor 
Administration  are  sufficient  to  enforce  correction  of  many  of  the 
conditions  which  have  heretofore  slowed  up  production.  Unless  this 
is  done  their  scope  of  usefulness  will  not  exceed  that  of  the  various 
advisory  committees. 

The  Women's  Division  of  the  Department  of  Labor  has  recently 
been  placed  under  the  direction  of  Miss  Mary  Van  Kleeck.  A  com- 
mittee representing  the  Office  of  the  Surgeon  General  of  the  Army,  the 
Ordnance  Department,  the  Navy,  the  United  States  Pubhc  Health 
Service,  the  National  Research  Bureau,  the  War  Industries  Board, 
the  Bureau  of  Standards  and  other  divisions  of  the  Department  of 
Labor  was  formed  in  June  (1918)  to  act  as  a  steering  committee  for  the 
Women's  Division. .  ThVough  their  work  several  investigations  of 
specific  industries  where  women  are  employed  have  been  made  and 
reports  subniitted  showing  the  hazards  of  this  work  and  what  correct- 
ive measures  are  necessary.  In  most  places  the  employers  have 
shown  a  very  marked  co-operative  spirit  and  have  taken  steps  to  im- 
prove conditions  on  the  recommendations  of  the  committee. 

The  real  value  of  this  committee's  work  and  of  all  other  such 
agencies  will  depend  upon  the  support  given  to  them  by  the  govern- 
ment. Will  the  failure  to  meet  their  recommendations  in  a  given 
industry,  where  conditions  are  detrimental  to  the  health  of  both  men 
and  women  employees,  be  sufficient  grounds  for  the  commandeering 
of  that  industry?     If  so  will  the  government  act? 


INDUSTRIAL   HYGIENE    AND    PRODUCTION  173 

The  commandeering  law  states  that  "wherever  production  is  ob- 
structed" such  a  step  can  be  taken.  The  hygienic  conditions  of  a 
plant  are  often  such  that  production  is  obstructed,  first  by  the  undue 
amount  of  sickness  resulting,  and  second  because  of  the  excessive  labor 
turn-over,  the  result  of  poor  working  conditions. 

If  commandeering  proceedings  should  be  adopted  on  these  grounds 
it  will  be  the  first  time  in  the  history  of  the  country  that  the  Federal 
government  has  interfered  with  private  corporations  because  of  lack 
of  protection  of  the  health  of  employees.  Such  a  precedent  would  have 
most  beneficial  results  on  the  public  health  of  the  nation. 

The  second  group  which  is  working  along  the  lines  of  industrial 
hygiene  is  the  Federal  Housing  Commission.  By  improving  the  hous- 
ing conditions  of  employees  one  of  the  most  important  steps  for  con- 
serving labor  will  have  been  taken.  Better  housing  conditions  means 
better  and  more  sanitary  living  conditions,  a  healthier,  more  contented 
working  force,  less  labor  turn-over  and  greater  production.  An  op- 
portunity is  given  to  this  commission  to  re-establish  homes  in  our 
industrial  centers,  homes  which  were  rapidly  being  displaced  by 
tenements  and  other  cheap  forms  of  abode. 

On  July  1st  of  this  year  the  President  issued  an  executive  order, 
under  the  powers  given  him  to  co-ordinate  the  work  of  various  depart- 
ments, which  will  have  the  most  far  reaching  effects  of  any  health 
measure  ever  enacted  in  this  country  providing  those  in  charge  of  the 
work  will  see  their  opportunity  and  take  full  advantage  of  it.  This 
order  states  that  "all  sanitary  or  public  health  activities  carried  on 
by  any  executive  bureau,  agency,  or  office,  especially  created  for  or 
concerned  in  the  prosecution  of  the  exisiting  war,  shall  be  exercised 
under  the  supervision  and  control  of  the  Secretary  of  the  Treasury." 
The  only  exception  to  this  is  the  work  of  the  medical  departments  of 
the  Army  and  Navy.  The  order  designates  the  U.  S.  Public  Health 
Service  of  the  Treasury  Department  as  the  agency  which  should  carry 
on  this  work. 

It  is  recognized  by  the  Public  Health  Service,  and  by  all  familiar 
with  its  activities,  that  the  most  important  work  it  is  d6ing  is  that 
of  its  Industrial  Hygiene  Section.  This  order  therefore  should  enable 
the  expansion  of  its  Industrial  Hygiene  work  to  include  every  industry 
in  the  country  which  is  concerned  either  directly  or  indirectly  in  the 
production  of  material  necessary  to  the  continuance  of  the  war. 

When  we  realize  that  the  Department  of  Labor  has  had  at  least  two 
groups,  with  physicians  employed,  working  in  this  field  of  industrial 
hygiene,  and  that  the  Bureau  of  Mines  has  had  a  medical  department 
working  in  the  same  field  and  that  at  least  five  other  medical  divisions 
of  the  various  departments  and  commissions  have  been  working  on 
public  health  matters,  then  we  can  better  understand  the  importance  of 


174  INDUSTRIAL   MEDICINE    AND    SURGERY 

this  executive  order.  The  duplication  of  function  in  this  field  of  public 
health  has  been  a  decided  factor  in  retarding  results.  It  is  the  plan 
of  the  Surgeon  General  of  the  Public  Health  Service  not  to  destroy 
or  duplicate  the  good  work  which  has  been  done  by  these  various  agen- 
cies, but  to  co-ordinate  their  work  and  henceforth  co-operate  under  one 
general  plan  of  procedure. 

Already  the  Public  Health  Service  has  thoroughly  co-operated  in 
the  work  of  the  Women's  Division  of  the  Department  of  Labor  by 
making  the  field  studies  in  Industrial  Hygiene  in  certain  chemical 
industries  and  turning  the  results  over  to  this  Division. 

Since  experiences  in  this  country  and  abroad  have  demanstrated 
so  clearly  that  the  principles  of  Industrial  Hygiene,  where  carried  out, 
always  result  in  increased  production,  it  is  evident  that  the  recom- 
mendations of  the  Public  Health  Service  should  receive  respectful 
attention  by  employers  at  this  time.  If  faulty  conditions  are  left 
uncorrected,  and  as  a  result  lowered  health  conditions  among  employ- 
ees slow  up  production,  it  would  seem  logical  for  the  federal  govern- 
ment to  take  over  and  operate  these  concerns  under  the  most  up-to- 
date  methods. 

Last  October  a  committee  was  formed  in  the  Medical  Section  of 
the  Council  of  National  Defense  consisting  of  members  from  the 
American  Association  of  Industrial  Physicians  and  Surgeons  and  from 
the  American  Railway  Surgeons  Association,  known  as  the  Committee 
on  Industrial  Medicine  and  Surgery.  This  committee  was  reorganized 
in  March  of  this  year  to  include  in  its  membership  representatives  of 
the  United  States  Public  Health  Service,  the  Department  of  Agricul- 
ture, the  Department  of  the  Interior,  the  Department  of  Commerce, 
the  Department  of  Labor,  organized  industry,  organized  labor,  or- 
ganized medicine,  organized  Industrial  medicine  and  the  Medical 
Department  of  the  Army. 

While  its  functions  were  only  advisory  yet  there  is  no  question 
but  that  the  studies  and  report  of  this  Committee  on  Industrial 
Medicine  and  Surgery  have  been  strongly  instrumental  in  bringing 
about  the  present  status  of  industrial  hygiene  in  its  relation  to  war 
production. 

Just  what  the  relationship  is  between  industrial  hygiene  and 
production  can  best  be  explained  by  quoting  from  the  report  of  this 
committee  prepared  by  its  director.  Dr.  Otto  Geier : 

"The  Need  of  the  Hour. — More  production  of  war  materials  by 
the  second  line  of  defense. 

"Slowing  down  of  industry  caused^ — 1.  By  excessive  labor  turn- 
over.    Men  drifting  from  shop  to  shop,  therefore  untrained  and  with 
low  output — more  subject  also  to  accident  on  successive  new  jobs. 
''2.  By  physical  breakdown:  (a)  Due  to  unsanitary  conditions  of 


INDUSTRIAL    HYGIENE    AND    PRODUCTION  175 

shop  and  homes  (lack  of  medical  supervision),  (b)  Due  to  lack 
of  early  recognition  and  prompt  treatment  of  ailments  loading  to 
invalidism. 

"3.  By  absence  from  work:  (a)  Due  to  preventable  accidents. 
(6)  Due  to  failure  to  secure  prompt  and  efficient  surgical  attention 
when  injured. 

■'4.  By  lack  of  output  because  of  those  killed  or  permanently  dis- 
abled (number  said  to  be  more  annually  than  thirty  times  the  number 
of  soldiers  expected  to  be  permanently  disabled,  and  for  which  mil- 
lions have  been  provided  in  the  way  of  reconstruction  facilities). 

"Production  can  be  Definitely  Speeded  up  by  Protection  of 
the  Human  Machinery  from  Preventable  and  Unnecessary  Wear  and 
Tear,  Disease  and  Injury .^ — The  non-effectives  in  the  average  indus- 
try are  known  to  be  at  least  3  per  cent,  or  30  in  each  1000  on 
account  of  sickness  (study  of  750,000  workers,  U.S.P.H.S.),  may  go 
as  high  in  others  as  6  per  cent,  of  non-effectives.  Add  to  this  factor 
an  additional  per  cent,  for  absence,  falsely  claimed  to  be  due  to  sickness ; 
then  add  one-half  of  1  per  cent,  for  absence  on  account  of  lost  time  due 
to  accidents  and  we  have  a  total  absence  of  6  per  cent,  to  which  med- 
ical men  can  direct  their  efforts. 

"The  principles  of  industrial  medicine  and  surgery  intelligently 
applied  can  reduce  this  6  per  cent,  loss  to  3  per  cent.,  making  a  gain  of 
30  workers  on  the  job  in  every  1000. 

'^Additional  Saving. — A  cleaner  plant  and  healthier  workmen  will 
result  in  a  greater  output  per  man. 

"Other  By-products. — Better  relations  between  employer  and  em- 
ployee— more  sympathetic,  understanding — -comforts  and  conven- 
iences, cafeterias,  etc.,  supplied;  all  producing  a  better  esprit  de  corps 
resulting  in  less  labor  turn-over. 

"The  protection  of  the  health  of  the  community — women  and  chil- 
dren— quite  as  essential  as  the  health  of  the  workers.  Fully  30  per 
cent,  of  the  effective  medical  and  surgical  capacity  of  the  profession 
has  been  drawn  into  the  Army.  Tweiity-four  per  cent,  of  the  visit- 
ing hospital  forces  has  been  called  into  the  service.  This  indicates 
that  the  civil  population  does  not  possess  adequate  medical  service. 
Under  strain  of  war  conditions,  disease  and  injury  are  increased. 
To  ipaeet  the  discrepancy,  a  method  must  be  found  by  which  every 
physician  not  in  the  Army  may  give  his  maximum  result  with  his 
minimum  effort,  so  that  the  community  may  be  adequately  protected 
against  disease. 

''The  placing  of  the  physician  in  industry  accomplishes  that  need. 
By  applying  his  preventive  measures  to  the  large  industrial  unit  on 
an  intensive  scale,  the  industrial  physician  assists  the  community  in 


176  INDUSTRIAL   MEDICINE    AND    SURGERY 

its  health  efforts,  lessens  disease,  and  therefore  lessens  the  strain  on 
the  physicians  in  private  practice. 

'^Our  problem  therefore  is:  1.  To  meet  the  military  need  for  greatly 
increased  production. 

"2.  To  offset  the  drain  on  the  man  power  in  industry  brought 
about  by  raising  the  military  force. 

'3.  To  assure  adequate  medical  sevrice  for  the  civil  population. 

"To  meet  the  problem,  the  government  must:  1.  Provide  against  un- 
necessary human  waste  in  industry  and  society  during  the  war. 

'"2.  Increase  output  by  maintaining  workers  in  good  health. 

"3.  Avoid  preventable  deaths  and  disabilities  from  accident  and 
disease. 

"4.  Restore  to  full  producing  power  in  the  shortest  possible  time  the 
sick  and  injured  workers. 

"5.  Provide  healthful  places  in  which  to  work. 

*'6.  Provide  healthful  homes  and  communities  in  which  to  live." 

It  is  still  too  early  to  report  great  progress  in  this  country  in  these 
matters  of  improved  health  conditions  for  working  men  and  women. 
But  the  start  which  has  been  made  augurs  great  things  for  the  future. 

The  Ship-building  Board  was  one  of  the  first  large  governmental 
war  machines  to  recognize  the  need  of  introducing  industrial  hygiene, 
and  its  allies,  prevention  of  accidents  and  adequate  medical  and  surg- 
ical care,  into  all  its  yards  as  a  means  of  maintaining  and  increasing 
production.  The  health  conditions  of  many  of  the  communities  about 
these  yards  have  been  permanently  improved  by  the  drastic  action  of 
this  Board.  For  example  large  areas  in  New  Jersey  have  been  drained 
and  other  steps  taken  to  rid  them  of  mosquitoes  and  the  resulting 
malaria.  In  one  town  a  large  dump  heap  was  so  infested  with  rats 
as  to  be  a  constant  menace  to  health.  A  successful  rat  extermi- 
nation campaign  was  carried  out.  These  examples  point  out  the  lesson 
that  industrial  hygiene  to  be  successful  must  not  stop  within  the  con- 
fines of  the  industry  itself.  Thus  far  this  work  has  been  conducted 
under  the  direction  of  a  medical  officer  from  the  Medical  Department 
of  the  Army. 

In  all  of  the  arsenals,  ordnance  depots  and  most  of  the  government 
owned  munition  plants  a  comprehensive  system  of  industrial  medicine 
and  surgery  has  been  or  is  being  installed. 

The  division  of  Sanitation  and  Safety,  an  organization  of  the  Indus- 
trial Service  Section  of  the  Ordnance  Department  has  been  instru- 
mental in  improving  the  conditions  in  many  of  the  industries  engaged 
in  the  manufacture  of  ordnance  supplies.  Their  work  has  just  started 
and  promises  to  yield  excellent  results. 

The  United  States  Employees  Compensation  Commission  has 
recently  placed  safety  engineers  in  many  government  industries  where 


INDUSTRIAL   HYGIENE    AND    PRODUCTION  177 

civilians  are  employed  and  by  co-operating  with  the  United  States 
Public  Health  Service  and  with  the  Medical  Department  of  the  Army 
has  been  able  to  start  systems  of  industrial  hygiene  in  several  such 
industries.  By  arrangements  recently  made  between  this  commission 
and  the  Surgeon  General  injured  civilian  employees  from  some  of 
these  government  industries  have  been  admitted  to  the  military 
hospital  for  the  blind  at  Baltimore  to  receive  the  same  re-educational 
advantages  which  have  been  prepared  for  the  blinded  soldiers.  If 
the  government  will  extend  this  opportunity  for  reconstruction,  and 
re-education  when  necessary,  to  the  civilian  employee — the  indus- 
trial soldier — which  it  is  giving  to  the  military  disabled  soldier,  then 
it  will  be  more  nearly  meeting  its  full  obligation  to  its  citizens. 

The  Railroad  Administration  has  its  safety  department  and  is  co- 
operating with  the  medical  departments  of  railroads  to  improve  health 
conditions  for  railway  employees. 

We  have  a  few  examples  of  an  active  interest  on  the  part  of  state 
governments  in  industrial  health  conditions,  but  these  are  the  first 
examples  of  an  active,  constructive  federal  program  for  introducing 
industrial  hygiene  into  specific  industries. 

The  importance  of  this  step,  and  the  ever  increasing  results  which 
it  will  have  may  not  be  fully  appreciated  by  many.  But  to  those 
surgeons  in  industry  who  have  devoted  many  years  of  their  lives  to 
establishing  these  principles  of  industrial  hygiene,  and  to  their  lay 
allies,  who  have  so  thoroughly  supported  and  abetted  their  efforts, 
the  dawn  of  a  new  day  has  come;  never  again  will  we  return  to  those 
dark  ages  when  the  human  machine  was  worked  to  the  limit  without 
supervision  and  then  prematurely  scrapped  because  of  a  breakdown, 
often  the  direct  result  of  the  occupation. 

By  the  time  this  book  is  published  the  contents  of  this  chapter  will 
be  ancient  history  considering  the  rapidity  with  which  advances  are 
being  made. 

However,  it  is  history  which  shows  the  signs  of  the  time  pointing 
ever  to  one  inevitable  solution  of  these  problems  of  Industrial  Hygiene 
and  Public  Health,  namely,  a  centralized,  federal  Department  of 
Health  with  power  to  act. 

12 


CHAPTER  XVIII 

EPIDEMIOLOGY  IN  INDUSTRY 

ACUTE  RESPIRATORY  INFECTIONS,  ACUTE   CONTAGIOUS   DISEASES, 
TYPHOID  FEVER,  ETC. 

The  prevention  of  the  spread  of  epidemic  diseases  among  employees 
is  one  of  the  most  important  duties  of  the  medical  staff.  This  function 
has  not  been  sufficiently  recognized  in  the  past;  or,  in  speaking  of 
epidemics,  we  have  thought  only  of  the  acute  exanthemata  and  limited 
our  efforts  to  their  prevention. 

Wide  experience  in  industrial  practice  has  convinced  several  physi- 
cians that  many  diseases,  not  heretofore  recognized  as  such,  were 
infectious.  Even  those  conditions,  usually  considered  as  symptoms, 
and  which  attack  one  for  a  few  hours  or  a  day  and  are  so  commonplace 
as  not  to  drive  the  patient  to  a  doctor,  are  seen  by  the  physician  in 
industry.  Epidemics  of  these  ordinary  conditions  frequently  occur 
and  cause  great  loss  in  the  efficiency  of  the  working  force  even  though 
no  actual  loss  of  time  from  work  results.  The  following  examples 
wiU  better  illustrate  these  minor  epidemics. 

Colds. — These  are  so  ordinary  that  both  patients  and  physicians 
have  adopted  an  attitude  of  indifference  and  tolerance  toward  them; 
yet  the  damage  from  ''colds"  to  the  human  system  and  the  economic 
loss  to  industry  cannot  be  estimated.  In  the  winter  months  this  con- 
dition is  so  widespread  that  its  epidemic  nature  might  be  doubted, 
the  real  cause  being  considered  due  to  weather  conditions  and  exposure 
to  the  same. 

However,  the  author  has  witnessed  many  epidemics  of  "colds" 
in  the  summer  months.  For  example,  in  the  month  of  July,  with  the 
most  ideal  working  conditions,  six  or  eight  employees  from  the  same 
department  would  report  to  the  doctor's  office  with  "colds."  The 
next  day  fifteen  or  twenty  other  employees  from  this  department 
would  report  with  the  same  condition.  This  mild  epidemic  might  be 
limited  to  this  department  but  usually  a  great  number  of  people  from 
other  portions  of  the  plant  would  be  attacked  by  the  same  condition. 

The  signs  and  symptoms  of  these  "colds"  take  various  forms  but 
the  epidemics  are  usually  of  the  same  type.  At  one  time  all  the 
employees  reporting  will  have  a  profuse,  thin  nasal  discharge,  while 
again  the  coryza  will  be  very  slight  and  most  of  the  cases  will  complain 
of  hoarseness.     Another  time  the  "colds"  will  be  accompanied  with 

178 


EPIDEMIOLOGY    IN    INDUSTRY  179 

signs  of  sinus  infection  and  headaches  and  the  majority  of  the  cases 
will  show  this  involvement.  I  have  seen  ten  girl  employees  from  the 
same  department  report  during  the  course  of  a  day  with  slight  "colds" 
and  herpes. 

These  experiences  have  occurred  so  frequently  that  one  cannot 
doubt  the  contagiousness  of  "colds."  Educational  campaigns  among 
the  employees  are  the  best  means  of  combating  these  epidemics. 
Warnings  against  the  spread  of  the  condition;  instructions  as  to  eating, 
rest,  care  of  bowels,  bathing,  dress  and  other  habits;  protection  of 
fellow  employees  by  care  in  handling  the  handkerchief,  washing  of  the 
hands,  covering  the  mouth  in  sneezing,  never  using  the  common  towel 
or  cup,  keeping  things  that  might  be  handled  by  others  out  of  the 
mouth,  and  hundreds  of  other  like  suggestions,  can  be  made.  When 
"colds"  show  signs  of  becoming  epidemic  it  is  much  more  economical 
to  the  concern  to  send  these  employees  home.  The  active  treatment 
of  all  cases  of  "colds"  by  the  medical  staff  while  they  remain  at  work 
is  very  efficacious  in  controlling  this  condition.  Separate  the  em- 
ployee as  far  as  possible  from  his  fellow  employees.  Have  him  report 
to  the  doctor's  office  three  times  a  day  and  gently  swab  the  nasal 
passages  with  10  per  cent,  argyrol,  spray  with  a  weak  solution  of 
dichloramine-T  or  inhale  the  fumes  from  hot  tincture  of  benzoin.  These 
methods  adopted  early  will  abort  many  cases.  Urotropin  in  five  grain 
doses,  often  repeated,  is  of  benefit.  But  the  surest  methods  are  isola- 
tion and  education. 

A  wonderful  opportunity  is  given  these  physicians  in  industry  to 
study  this  condition  and  evolve  the  best  form  of  treatment  and  the 
best  means  of  preventing  "colds."  We  have  neglected  this  disease 
because  familiarity  with  it  has  bred  contempt. 

Lumbago. — ^Lumbago  occurs  in  endemic  forms  and  frequently  in 
such  proportions  as  to  indicate  an  epidemic.  It  is  not  limited  to  de- 
partments as  in  the  case  of  "colds"  but  often  during  the  course  of  a 
week  fifty  or  more  cases  of  this  condition  will  report.  I  have  seen  ten 
men  in  the  examining  room  at  the  same  time  all  complaining  of  pain 
in  the  back.     Men  are  more  susceptible  to  this  than  women. 

Torticollis  or.  "stiff  neck"  has  also  appeared  at  the  same  time  and 
in  numbers  suggesting  a  mild  epidemic.  One  morning  in  early  fall  the 
author  arose  with  a  stiff  neck.  While  at  breakfast  his  sister,  who  had 
been  with  him  the  night  before,  phoned  and  asked  what  she  could  do  for 
a  stiff  neck.  At  the  plant  that  morning  fourteen  employees  reported 
complaining  of  stiff  necks,  four  were  from  the  same  department.  At 
his  office  in  the  same  afternoon  one  patient  called  ,on  account  of  this 
condition.  On  the  same  day  and  for  several  days  following  lumbago 
was  very  prevalent  among  the  employees. 

The  real  origin  of  these  conditions  is  undoubtedly  from  some  focus 


180  INDUSTRIAL   MEDICINE    AND    SURGERY 

of  infection  within  the  patient's  own  body.  In  the  case  of  both  stiff 
neck  and  lumbago,  diseased  teeth,  hypertrophied  tonsils,  or  a  chronic 
coryza  can  usually  be  found.  Nevertheless  when  there  is  a  sudden 
flare-up  of  these  conditions  in  a  number  of  people  at  the  same  time  one 
is  forced  to  speculate  on  the  possibility  of  a  spread  of  the  trouble  from 
one  individual  to  another,  or  on  what  changes  in  the  weather  or  the 
environment  cause  a  lowered  resistance  among  individuals  with  an 
increased  virulence  in  the  infecting  organism. 

These  minor  conditions,  so  long  considered  as  a  necessary  annoy- 
ance in  our  everyday  life,  need  careful  study  and  analysis.  The  reduc- 
tion in  their  occurrence  will  be  one  of  the  greatest  economies  in  the 
industrial  world. 

TONSILLITIS— INFLUENZA— PNEUMONIA 

The  acute  respiratory  infections  have  become  more  and  more  preva- 
lent during  the  last  five  years.  Employees  have  always  lost  consider- 
able time,  especially  during  the  winter  months,  from  these  causes,  but 
recently  they  have  occurred  in  such  numbers  as  to  be  classed  as  epi- 
demics. Time  and  again  the  absenteeism  has  reached  such  a  high 
rate  as  to  materially  interfere  in  production  and  output.  The  efforts 
to  prevent  these  epidemics  have  caused  the  physician  in  industry  more 
worry  than  almost  any  other  condition. 

These  acute  respiratory  conditions  have  occurred  as  epidemics  of 
tonsillitis,  usually  the  severe  form  of  streptococcic  sore  throat ;  influ- 
enza or  ''grippe;"  pneumonia,  especially  streptococcic  pneumonia, 
and  bronchopneumonia;  with  their  complications. 

Previous  to  1912  the  employees  in  the  concern  the  author  was  con- 
nected with  were  not  affected  to  any  unusual  degree  by  these  diseases. 
But  in  1912  the  working  force  was  swept  with  an  epidemic  of  severe 
colds  and  tonsillitis.  Again  in  the  winter  of  1913  an  epidemic  of  tonsil- 
litis occurred.  These  cases  were  usually  of  a  severe  streptococcic  form 
and  accompanied  by  many  complications.  These  epidemics  were 
widespread  but  Chicago  seemed  especially  affected.  Capps  and  Miller 
and  Preble  of  that  city  all  described  the  condition  as  a  hemolytic 
streptococcus  infection.  Milk  was  thought  by  them  to  be  the  agency 
through  which  it  was  carried. 

In  1914  the  condition  was  not  so  serious  but  beginning  in  the  early 
winter  of  1915  and  continuing  until  March,  1916,  the  entire  country 
was  included  in  an  epidemic  of  so-called  "grippe"  which  was  most  fre- 
quently complicated  by  pneumonia.  In  1 9 1 6  this  disease  was  prevalent 
but  not  to  any  such  extent  as  the  previous  year. 

We  all  know  the  fearful  toll  which  these  acute  respiratory  diseases 
have  claimed  in  our  Army  during  the  last  year  and  a  half.  At  their 
outset  they  have  taken  various  forms.     In  some  camps  measles  and 


EPIDEMIOLOGY    IN    INDUSTRY  181 

mumps  were  the  starting  point  of  the  epidemic,  followed  by  influenza, 
pneumonia,  pleurisy  with  effusion  and  empyema.  Practically  all  of 
the  reports  show  the  hemolytic  streptococcus  with  or  without  pneumo- 
cocci,  Types  I,  II,  III  and  IV,  as  the  commonest  organism  in  these 
epidemics  among  the  soldiers.  In  some  camps  the  epidemic  began  as 
influenza;  in  others  epidemics  of  primary  streptococcic  pneumonia 
were  reported,  while  in  still  others  the  epidemic  was  secondary  to  the 
acute  exanthemata. 

In  industry  the  same  conditions,  usually  classed  as  influenza,  have 
been  claiming  their  toll  from  the  civilian  population.  I  am  told  by 
some  physicians  in  industry  that  these  epidemics  do  not  differ  to  any 
extent  from  the  epidemic  of  1915  except  empyema  as  a  complication 
has  been  more  prevalent. 

This  hasty  resume  demonstrates  that  these  acute  respiratory  in- 
fections have  been  gradually  increasing  in  this  country  for  the  last 
six  years.  Each  new  epidemic  has  undoubtedly  increased  the  viru- 
lence of  these  infecting  organisms.  The  crowding  together  of  thou- 
sands of  young  men  in  camps  facilitated  the  spread  of  the  disease. 
At  the  same  time  the  speeding  up  of  industry  and  the  overcrowding 
that  was  necessary  because  of  the  war  emergency  made  excellent 
epidemic  environment. 

A  description  of  the  epidemic  of  1915  written  by  the  author  is  in 
the  main  characteristic  of  all  these  acute  respiratory  epidemics  which 
undoubtedly  are  very  closely  related  in  both  cause  and  effect. 

During  December,  1915,  and  January  and  February,  1916,  our 
country,  especially  the  Northern  States,  was  swept  with  an  epidemic 
resembling  in  almost  all  of  its  aspects  the  pandemic  disease  known  as 
influenza  which  swept  over  the  entire  world  in  1889  and  1890.  From 
all  reports,  the  East — New  York,  New  Jersey,  Pennsylvania  and  Ohio 
— and  the  Northwestern  States — especially  Minnesota  and  North  and 
South  Dakota  and  extending  into  Canada,  suffered  to  the  greatest 
extent  from  this  epidemic. 

Because  of  our  medical  work  among  the  employees  of  certain  large 
industries  in  Chicago  and  through  the  various  channels  of  examin- 
ing employees  for  occupational  diseases,  we  had  an  unusual  opportu- 
nity of  studying  over  1800  cases  affected  by  this  epidemic  disease. 

Etiology. — -Clinically,  the  disease  corresponded  in  practically  all 
of  its  aspects  with  the  old  epidemic  of  influenza  so  well  described  by 
Osier,  Laden  and  Senator,  and  Lichtenstern,  and  many  others  follow- 
ing the  epidemic  of  1890.  But  from  a  bacteriologic  standpoint,  we 
did  not  find  the  bacillus  of  influenza  as  described  by  Pfeiffer  in  1892. 
From  twenty-five  blood  cultures  and  a  great  number  of  cultures  made 
from  the  secretions  from  the  nose  and  throat  of  the  affected  indi- 
vidual,  grown   on  blood   agar,   the   organism  usually  found   was  a 


182  INDUSTRIAL   MEDICINE    AND    SURGERY 

hemolytic  streptococcus,  often  associated  with  the  pneumococcus. 
Unfortunately  the  isolation  of  the  various  types  of  pneumococci  were 
not  carried  out  in  1915  as  they  are  to-day. 

During  the  winter  of  1912-13,  especially  during  January  and 
February,  Chicago  was  swept  by  an  epidemic  of  a  very  severe  form 
of  tonsillitis.  At  the  same  time  there  was  an  epidemic  resembling 
very  much  the  old  so-called  catarrhal  fever,  characterized  by  a  severe 
coryza  and  a  tendency  for  the  infection  to  spread  to  the  sinuses,  espe- 
cially the  frontal  sinus  and  the  antrum.  The  cases  were  often  quite 
severe  and  the  course  of  the  disease  prolonged.  Bacteriologic  studies 
of  these  epidemics  were  made  by  many  observers,  but  as  a  rule  either 
a  hemolytic  streptococcus  or  a  diplococcus  was  found  as  the  cause  of 
the  infection.  Again,  last  winter  we  had  an  epidemic  characterized 
by  fewer  cases  of  tonsillitis,  but  by  more  cases  of  the  nasal  infection 
and  accompanied  by  pharyngitis,  laryngitis,  and  often  bronchitis. 
Again  the  streptococcus  and  diplococcus  were  found  as  the  most  fre- 
quent organisms  in  the  nasal  and  throat  secretion  of  these  cases.  As 
in  the  present  epidemic,  the  patients  were  usually  told  that  they  had 
the  "grippe,"  although  as  pointed  out  the  influenza  bacillus  had  not 
been  found  in  any  of  these  epidemics  of  the  last  three  years. 

Lichtenstern,  in  his  article  in  Nothnagel's  Handbuch,  in  1898, 
pointed  out  the  relationship  between  the  epidemic  influenza  to  the 
ordinary  influenza  cold  or  catarrhal  fever,  which  is  usually  present 
in  all  communities.  He  makes  three  divisions:  First,  the  pandemic 
influenza,  vera,  caused  by  the  Pfeiffer  bacillus;  second,  epidemic 
influenza,  vera,  which  develops  for  several  years  in  succession  after  a 
pandemic  and  is  also  caused  by  the  same  bacillus;  third,  the  endemic 
influenza  or  pseudo-influenza  or  catarrhal  fever,  commonly  called 
the  "grippe"  and  which  is  due  to  an  unknown  organism. 

During  the  period  from  1912  to  1915,  in  the  winter  months,  we 
witnessed  an  epidemic  increasing  in  severity  until  it  culminated  in  the 
disastrous  epidemic  of  1915-16  and  resembled  clinically  the  true 
influenza  disease.  But,  instead  of  the  influenza  bacillus,  the  hemo- 
lytic streptococcus  mixed  with  the  pneumococcus  has  been  the  real 
cause  of  these  epidemics. 

The  disease  was  highly  contagious.  When  a  member  of  a  family 
was  stricken,  it  usually  attacked  the  entire  household.  It  spread 
throughout  the  schoolroom,  attacking  both  the  teachers  and  the  pupils. 
The  most  significant  feature  of  the  contagion  was  the  way  in  which  it 
spread  among  the  clerical  forces  of  the  department  stores  and  among  the 
employees  of  those  industries  which  were  forced  to  speed  up,  to  work 
overtime  and  to  take  on  extra  employees  in  order  to  handle  the  Christ- 
mas rush  of  business.  In  one  office,  which  is  always  rushed  to  the 
limit  by   increased  Christmas  business,   50  per   cent,   of  the  office 


EPIDEMIOLOGY   IN   INDUSTRY  183 

force  was  ca.ught  by  this  epidemic.  In  certain  industries,  or  in 
departments  which  were  not  affected  by  this  extra  Christmas  work, 
the  disease  did  not  spread  to  any  extent,  and  frequently  missed  them 
altogether. 

Whenever  one  or  two  cases  developed  in  a  room  containing  a  great 
many  employees,  it  was  not  uncommon  to  see  sixty  or  eighty  cases 
develop  in  that  same  room,  within  the  course  of  a  week.  In  many 
industries,  a  vicious  circle  was  easily  developed.  The  excess  of  work 
caused  a  spread  of  the  disease,  and  the  more  employees  that  became  sick, 
the  harder  did  the  others  have  to  work.  Those  employed  in  outside 
work  suffered  far  less  than  the  inside  workers.  The  hospitals,  especially 
such  institutions  as  the  Cook  County  Hospital  were  overcrowded  with 
patients.  As  a  result,  the  nurses  and  hospital  help  were  greatly 
overworked.  The  disease  spread  with  alarming  rapidity  among  the 
nurses.  One  hospital  had  25  per  cent,  of  their  nurses  sick  at  one  time. 
Due  to  being  "too  busy,"  a  great  many  of  the  above  employees,  and 
very  likely  the  nurses  neglected  their  bowels — constipation  resulted; 
many  neglected  to  eat  their  regular  meals  or  to  take  sufficient  time 
to  eat ;  and  many,  due  to  working  overtime,  did  not  get  sufficient  sleep 
or  time  to  recuperate  from  one  day  to  the  next. 

From  a  study  of  the  above  facts,  it  would  seem  that  the  chief  pre- 
disposing causes  to  the  spread  of  this  epidemic  were  overwork  (es- 
pecially inside  work) ,  overcrowding,  and  the  neglect  of  the  fundamental 
principles  of  health — namely,  sufficient  food  and  rest,  regular  meal- 
times, and  proper  elimination. 

The  spread  of  this  disease  from  one  individual  to  another  was 
undoubtedly  through  the  nasal  and  respiratory  secretions  carried  by 
the  infected  dust  and  other  material  of  the  working  room.  The 
actual  onset  of  the  disease  was  usually  preceded  by  a  coryza,  sneez- 
ing, and  the  ordinary  symptoms  of  "catching  cold."  Undoubtedly 
the  careless  sneezing  and  careless  flipping  about  of  the  soiled  hand- 
kerchief of  the  affected  individual  was  the  commonest  means  of 
communicating  the  infection  to  his  fellow  workers,  fellow  passengers 
in  the  street  car,  or  any  others  who  came  in  close  contact  with  him. 
Other  sources  were  careless  spitting,  careless  blowing  of  the  nose 
without  using  a  handkerchief,  the  common  towel,  which  can  so  easily 
collect  secretions  from  the  nose  or  mouth,  the  common  drinking 
cup,  kissing,  and  the  handling  of  articles  used  by  the  affected 
individual.  One  had  only  to  walk  through  our  busy  shopping  dis- 
tricts, just  prior  to  Christmas  in  order  to  see  how  many  of  both  the 
clerks  and  the  customers  had  "colds;"  to  see  how  frequently  and  how 
carelessly  handkerchiefs  were  jerked  from  pockets  and  shaken  in  the 
air  in  order  to  spread  them  out;  to  behold  customers  sneezing  into 
their  hands,  then  handling  articles  which  were  later  bought  by  other 


184  INDUSTRIAL    MEDICINE    AND    SURGERY 

purchasers;  and  to  note  the  overcrowding  everywhere,  especially  in 
the  ill-ventilated  basement  salesrooms,  in  order  to  understand  how 
such  an  epidemic  could  spread  to  almost  every  household  in  the 
city.     In  fact,  one  marvels  that  anybody  escaped. 

Symptoms.— We  had  the  unusual  opportunity  of  seeing  several 
hundreds  of  these  cases  of  this  epidemic  disease  at  their  onset,  plus  the 
questionable  privilege  of  studying  the  disease  as  fellow  sufferers.  The 
majority  of  the  cases  reported  to  the  doctor  because  of  a  severe  cold 
in  the  head,  a  slight  sore  throat,  and  a  general  aching  throughout  the 
body,  usually  complaining  of  backache,  legache,  or  headache,  in  the 
order  named.  In  every  case  the  temperature  and  pulse  were  taken 
at  once,  and,  as  a  rule,  fever  was  always  present,  varying  from  100  to 
103.  The  pulse  was  invariably  slow  in  comparison  to  this  tempera- 
ture, averaging  from  80  to  90.  Some  of  these  complained  of  a  severe 
cough,  but  as  a  rule  the  bronchitis  symptoms  developed  later.  In 
practically  all  cases,  there  was  a  history  of  prodromal  symptoms, 
varying  from  one  or  two  days  to  a  week,  such  as  a  marked  coryza 
or  sneezing,  headaches,  or  a  general  feeling  of  lassitude.  Many 
complained  of  constipation  and  others  of  sleeplessness  and  loss  6f 
appetite. 

In  about  5  per  cent,  of  the  cases  the  onset  was  that  of  a  gastro- 
intestinal disturbance.  Nausea  was  marked,  frequently  there  would 
be  severe  vomiting.  Occasionally  diarrhea  was  present,  but  con- 
stipation was  the  rule.  Frequently,  severe  abdominal  pains  were 
complained  of,  and  oftenest  the  pain  was  located  in  the  left  hypo- 
chondriac region,  near  the  spleen.  Fever  was  practically  always 
present.  Because  of  the  abdominal  symptoms  a  blood  count  was 
usually  made,  but  it  was  seldom  that  the  leukocytes  were  above  14,000. 
In  a  smaller  percentage  of  the  cases,  the  onset  was  very  abrupt  and 
was  marked  by  profound  prostration.  The  patient  would  suddenly 
collapse  while  at  his  work.  The  pulse  would  become  almost  imper- 
ceptible and  the  surface  of  the  body  clammy  and  cold.  In  some  of  these 
cases,  the  temperature  would  be  quite  high,  103  or  104,  and  in  two 
cases  as  high  as  105^;  while  in  others  it  would  be  subnormal. 
After  getting  the  patient  in  bed  and  administering  stimulants, 
these  signs  of  collapse  would  rapidly  disappear.  Neither  did  these 
cases  seem  to  run  a  more  serious  or  more  prolonged  course  than 
the  others  with  the  milder  onset.  In  those  with  the  severe  onset  the 
leukocyte  count  was  usually  5000  to  7000.  Leukopenia  was  very 
common  following  the  illness. 

The  symptoms  most  characteristic  of  this  disease  were  the  following: 

Coryza.- — This  was  by  far  the  commonest  symptom,  beginning 
early  in  the  prodromal  stage,  and  continuing  through  the  course  of 
the  disease,   even  persisting  after  the  patient  was  able  to  resume 


EPIDEMIOLOGY    IN    INDUSTRY  185 

his  usual  duties.  The  nasal  secretion  was  very  profuse  and  watery 
at  first,  but  later  tenacious  in  character. 

Sore  Throat. — With  only  few  exceptions  every  case  had  a 
markedly  injected  throat,  the  soft  palate,  pillars  and  pharynx 
usually  being  involved.  Frequently  the  uvula  and  soft  palate 
were  dotted  with  vesicles — in  fact  this  was  such  a  common  finding 
that  it  could  be  called  characteristic  of  the  throat  condition.  In 
those  patients  with  hypertrophied  tonsils,  these  were  usually  found 
infiamed.  As  a  rule,  there  was  a  decided  discrepancy  between  the 
subjective  symptom  and  the  marked  inflammatory  change  in  the  throat. 

Myositis.- — Practically  every  case  had  a  certain  amount  of 
backache  and  legache.  In  some,  the  aching  in  the  muscles  was  acute 
and  was  the  most  bitterly  complained  of  symptom.  At  times,  this 
was  accompanied  by  a  sciatica  or  other  form  of  neuritis. 

Headache. — This  was  usually  complained  of  in  the  early  course 
of  the  disease.  It  was  commonly  located  in  the  frontal,  temporal 
region,  and  caused  the  patient  to  complain  of  dizziness  on  moving. 

Chill. — An  actual  chill  was  uncommon,  but  cold  extremities 
and  chilly  sensations  all  over  the  body,  was  the  rule. 

Fever. — This  was  present  in  the  majority  of  cases  at  the  onset. 
It  was  characteristic  for  the  temperature  to  be  normal  in  the  morning, 
but  up  again  in  the  evening.  In  most  cases  the  temperature  would 
disappear  after  two  or  three  days.  The  average  temperature  was 
100°  to  101°,  but  as  stated  before  it  occasionally  rose  very  high, 
even  to  105.5.  The  temperature  depended  a  great  deal  upon  the  pa- 
tient's keeping  quietly  in  bed  until  the  symptoms  disappeared. 

Pulse. — ^This  varied  between  80  and  100,  but  the  slow  pulse  was 
the  most  characteristic. 

Bronchitis. — This  was  a  very  frequent  symptom.  The  cough 
was  most  often  paroxysmal  in  character,  especially  at  first. 
The  sputum  early  was  thin  and  frothy  and  usually  contained  small, 
white  particles.  In  many  cases  this  symptom  subsided  without  any 
further  development;  in  others,  the  bronchitis  would  persist  and  the 
.sputum  would  become  thick,  yellowish,  and  purulent.  The  hemo- 
lytic streptococcus  could  usually  be  found  in  this  type  of  sputum. 
As  a  rule,  those  cases  ran  the  longest  course  which  developed  the  most 
marked  coryza  and  bronchitis.  The  examination  of  the  lungs  when 
bronchitis  was  present  invariably  showed  fine,  subcrepitant  rales  over 
the  upper  lobes.  It  was  seldom  that  any  other  signs  were  present. 
Pleurisy  was  very  uncommon. 

Herpes. — Herpes  about  the  nose  and  on  the  lip  were  present  in 
a  few  cases,  but  were  not  the  rule,  as  pointed  out  in  the  true  influenza 
epidemic. 

Delirium. — This    was    not    noticed   in    any   of    the    cases  which 


186  INDUSTRIAL   MEDICINE    AND    SURGERY 

came  under  our  observation.  Neither  were  other  nervous  manifesta- 
tions noticed  to  any  extent. 

The  above  symptoms  were  those  which  were  commonly  noted  at 
the  outset  of  this  disease  when  the  employees  reported  to  the  doctor's 
office. 

Course  of  the  Disease. — The  average  length  of  time,  in  1000  cases, 
for  the  disease  to  run  its  course  was  five  and  three-fourth  days.  Some 
recovered  in  twenty-four  to  forty-eight  hours,  while  in  others  the  disease 
persisted  for  three  to  six  weeks.  The  course  of  the  disease  was  undoubt- 
edly cut  short  by  taking  it  in  time  and  adopting  active  treatment  at 
once.  The  most  prolonged  cases  were  those  who  persisted  in  working 
several  days  after  the  symptoms  of  the  disease  had  manifested  them- 
selves. Likewise  the  course  was  prolonged  by  patients  getting  up  and 
about  as  soon  as  they  began  to  feel  better,  instead  of  remaining  in  bed  a 
few  days  after  the  symptoms  had  subsided.  Relapses  were  very  com- 
mon, especially  among  those  who  returned  to  work  too  soon.  As  a  rule 
when  a  relapse  did  occur,  the  symptoms  were  much  more  severe 
than  in  the  original  attack. 

Complications. — Pneumonia  was  by  far  the  most  frequent  com- 
plication of  this  epidemic  of  1915.  Most  of  the  deaths  reported  were 
due  to  pneumonia.  In  some  cities  the  death  rate  from  pneumonia 
increased  four  and  five  times,  as  compared  with  the  year  previous. 
In  Chicago  the  number  of  pneumonia  deaths  for  the  week  end- 
ing December  11,  1915,  was  77;  during  the  week  ending  December  18th, 
the  number  was  108;  for  the  week  that  ended  Christmas  Day,  the 
number  was  205,  while  the  corresponding  week  a  year  before  the 
pneumonia  deaths  totaled  only  73.  In  talking  with  numerous 
physicians  and  different  Board  of  Health  officials,  it  was  agreed  by  all 
that  these  increased  pneumonia  deaths  were  the  terminal  results  of 
this  so-called  influenza  epidemic. 

Pleurisy  with,  effusion  and  empyema  were  reported  by  many  doc- 
tors as  a  cause  for  the  long  continued  absence  of  employees  from  work 
following  an  attack  of  this  infection. 

Various  forms  of  neuritis,  especially  lumbago  were  common  com- 
plications. In  examining  a  great  many  of  these  patients  after  they 
had  recovered  from  an  attack  of  this  disease,  a  number  were  found  with 
rapid,  irregular  hearts  and  other  signs  of  a  distinct  myocarditis.  A 
few  cases  of  otitis  media  both  serous  and  purulent  and  of  mastoiditis 
were  reported.  It  was  not  uncommon  to  find  many  cases  of  gastro- 
intestinal disturbance,  following  an  attack  of  this  epidemic,  and  a  few 
cases  were  seen  of  cholecystitis  accompanied  with  marked  jaundice. 
Relapses  or  recurring  attacks  of  the  disease  were  very  common.  The 
greatest  number  of  these  occurred  from  one  to  two  days  after  the 
patient  had  recovered  from  his  original  attack  and  had  returned  to 


EPIDEMIOLOGY    IN    INDUSTRY  187 

work;  but  a  number  of  secondary  attacks  occurred  as  long  as  two  and 
three  weeks  after  the  patient  had  returned  to  work. 

Many  remote  complications  developed  among  the  employees  who 
had  suffered  from  this  epidemic  infection,  and,  while  the  connection 
could  not  always  be  traced,  yet  we  felt  justified  in  holding  this  so-called 
influenza  attack  responsible. 

Within  a  period  varying  from  two  to  eight  weeks  after  their 
return  to  work,  four  men  developed  cases  of  acute,  suppurative  mastitis 
without  any  history  of  trauma  to  the  gland.  In  two  of  these  strepto- 
cocci were  found  and  in  two  both  streptococci  and  staphylococci. 

Hand  infections  following  slight  injuries  were  more  prevalent  in 
January,  February,  and  March  following  this  epidemic  than  in  any 
other  equal  period  of  my  connection  with  this  plant.  Four  cases  of 
very  slight  scratches  developed  lymphangitis  followed  by  large  axil- 
lary abscesses.  All  four  of  these  employees  had  suffered  a  short 
time  before  from  the  epidemic  infection. 

Five  employees  shortly  after  their  return  to  work  developed 
severe  abdominal  pains,  rigidity  and  diffuse  tenderness.  The  leu- 
kocyte count  was  below  14,000  in  all  of  these.  The  cases  resembled 
acute  appendicitis.  One  was  operated  but  the  appendix  was  only 
slightly  injected.  These  cases  corresponded  to  the  descriptions 
of  abdominal  complications  which  were  prevalent  during  the  epidemic 
and  were  described  as  acutely  inflamed  mesenteric  glands. 

Swollen  glands  of  the  neck  were  seen  in  several  cases  follow- 
ing the  attack  but  only  two  of  these  suppurated. 

One  case  of  cellulitis  of  the  abdominal  wall  and  another  of  cellu- 
litis of  the  thigh  followed  slight  injuries  to  these  parts  in  two  men 
who  had  shortly  before  had  the  ''grippe." 

In  March,  1916,  eighteen  cases  of  tuberculosis  were  found  among 
the  employees.  All  of  these  had  suffered  during  the  winter  from  the 
epidemic.  Twelve  of  these  cases  had  been  examined  during  the  year 
previous  to  the  attack  and  no  signs  of  tuberculosis  had  then  been 
discovered.  This  bears  out  the  experience  of  others  that  these  acute 
respiratory  infections  frequently  tend  to  light  up  latent  tuberculous 
areas. 

These  remote  complications  demonstrate  that  the  economic  loss  to 
industry  from  these  increasing  epidemics  of  streptococcic  sore  throat, 
streptococcic  pneumonias,  and  streptococcic  respiratory  infections 
grafted  on  influenza  or  other  acute  infections  continue  for  months 
after  the  acute  epidemic  has  subsided. 

Treatment. — The  extensiveness  of  these  epidemics,  the  greatly 
increased  death  rate,  and  the  incalculable  economic  loss  to  the  com- 
munity and  to  practically  all  of  the  industrial  concerns,  has  presented 
many   problems,    not   only  to   the  health   department  but  to  those 


188  INDUSTRIAL   MEDICINE    AND    SURGERY 

physicians  engaged  in  industrial  medical  work.  The  greatest  problem 
in  the  line  of  treatment  is  the  prevention  of  the  spread  of  such 
epidemics. 

Various  health  departments  have  done  invaluable  work  through 
their  newspaper  campaigns  of  educating  the  public  concerning  the 
importance  of  isolating  every  case  of  this  disease  and  their  warnings 
concerning  the  danger  of  sneezing,  promiscuous  kissing,  the  use  of 
the  common  towel,  and  all  other  means  by  which  the  secretion  of 
the  affected  individual  infect  his  fellows.  The  source  of  greatest 
menace  to  the  public  and  one  which  is  practically  uncontrollable  by 
a  health  department  is  the  early  case  who  was  not  sick  enough  to  re- 
main at  home  the  first  two  or  three  days  of  his  attack,  the  light  case 
who  in  spite  of  his  symptoms  is  able  to  stick  it  out  and  remain  at 
work  every  day,  or  the  serious  case  who,  as  soon  as  he  feels  better 
mingles  with  the  public  before  he  ceases  to  be  a  menace  as  an  infection 
carrier.  More  harm  is  done  by  these  three  classes  than  all  the  other 
cases  put  together,  and  in  the  future  a  great  amount  of  education 
needs  to  be  directed  toward  these  groups.  It  behooves  the  entire 
medical  profession  to  recognize  the  infectious  nature  of  this  disease  and 
to  use  the  same  precautions  toward  it  that  we  do  toward  diphtheria 
and  scarlet  fever. 

The  medical  staffs  of  various  large  industries,  and  there  are  a 
number  of  such  staffs  now,  found  a  task  of  great  magnitude  on  their 
hands  in  combating  this  epidemic  of  1915.  They  were  forced  to  face  two 
problems  in  this  work:  First,  to  prevent  the  spread  of  the  epidemic 
among  the  employees;  and  second,  to  be  sufficiently  conservative 
in  their  efforts  as  not  to  cripple  the  business,  especially  as  there  was 
an  excessive  amount  of  work,  due  to  the  Christmas  rush.  As  soon 
as  we  recognized  that  an  epidemic  was  among  us,  our  medical  staff 
took  steps  to  subtly  re-enforce  the  rules  which  are  always  in  force 
concerning  sickness.  We  notified  every  manager,  floor  manager  and 
division  head  to  send  every  employee  who  showed  signs  of  "catching 
cold"  or  other  signs  of  this  disease  to  the  doctor's  office  at  once. 
Likewise,  no  employee  was  allowed  to  go  home  on  account  of  sickness 
without  reporting  to  the  doctor's  office  first,  and  no  employee  was 
allowed  to  return  to  work  after  being  home  on  account  of  sickness 
without  first  securing  a  permit  from  the  doctor's  office.  This  gave  the 
opportunity  of  examining  all  those  who  were  sick  and  of  sending 
those  who  showed  signs  of  this  disease  home  at  once,  and  of  keeping 
them  away  from  the  department  until  they  had  fully  recovered.  A 
number  who  had  apparently  recovered  were  allowed  to  return  to 
work,  but  as  stated  elsewhere,  relapses  were  not  uncommon.  No 
opportunity  was  neglected  to  instruct  the  individual  employee  in  the 
various  means  of  preventing  the  spread  of  this  infection. 


EPIDEMIOLOGY    IN    INDUSTRY  189 

Two  of  our  best  methods  of  prevention  were  frequent  airing  out 
of  the  various  departments  and  the  formaldehyd  fumigation  of 
the  departments  overnight.  The  necessity  of  throwing  open  all 
the  windows  of  the  department  for  two  or  three  hours  in  order  to 
rid  the  room  of  the  formaldehyd  was  undoubtedly  one  of  the  great 
benefits  of  the  fumigation.  Thus  our  efforts  toward  prevention  were 
directed  along  four  very  definite  lines :  First,  the  ridding  of  the  depart- 
ment of  the  affected  individuals  as  rapidly  as  possible;  second,  educa- 
ting the  employees  concerning  their  individual  responsibility  toward 
preventing  the  spread  of  the  infection ;  third,  the  plentiful  use  of  fresh 
air;  fourth,  the  frequent  fumigation. 

Active  Treatment. — We  early  recognized  that  a  great  many  of  the 
employees  did  not  consider  the  sickness  sufficiently  serious  to 
consult  a  physician,  thus  often  needlessly  prolonging  their  disability. 
We  began  therefore  to  ascertain  from  each  sick  employee  the 
name  of  his  family  physician  and  insisted  upon  them  calling  him 
in  as  soon  as  they  reached  home.  In  a  great  many  cases  we  called 
the  family  physician  and  made  sure  that  he  was  on  the  job.  Many 
had  only  a  light  attack  of  the  disease  and  did  not  feel  sufficiently  sick 
to  call  in  a  physician,  while  others  did  not  have  family  physicians. 
To  these  we  frequently  gave  a  prescription  for  aspirin,  or  sodium 
salicylate  to  be  taken  in  ten  grain  doses  every  two  hours.  Likewise 
they  were  given  a  cathartic  of  castor  oil  or  magnesium  sulphate  at 
once,  and  a  gargle  of  Dobell's  solution,  and  were  then  sent  home 
and  told  to  use  the  medicine  as  directed  and  stay  in  bed  for  at  least 
two  days.  Our  visiting  nurse  called  on  as  many  of  these  as  possible 
and  made  sure  that  they  were  following  out  these  directions.  In 
this  way  many  of  these  early  cases  were  aborted  and  the  employees 
were  able  to  return  to  work  within  two  or  three  days.  By  this  careful 
supervision  and  with  the  aid  of  our  visiting  nurses,  most  of  our  patients 
received  active  treatment  for  this  disease  from  its  onset.  In  this  way 
many  of  them  were  saved  from  serious  complications  and  the  length 
of  their  disability  was  greatly  reduced. 

Results. — While  the  death  rate  from  pneumonia  complicating 
the  epidemic  was  increasing  to  3  and  4  times  the  normal  rate  through- 
out the  city,  yet  among  the  1800  cases  occurring  among  these 
employees  there  were  only  three  deaths,  all  due  to  pneumonia. 

Three  other  large  concerns  in  Chicago  reported  an  absentee  rate 
of  from  25  per  cent,  to  35  per  cent,  of  their  total  working  force  during 
this  epidemic.  In  this  concern  12  per  cent,  of  the  employees  were 
involved.  One  physician  reported  8  per  cent,  of  the  employees 
he  was  responsible  for  as  absent  on  account  of  influenza,  while  a 
neighboring  concern  had  40  per  cent,  of  their  employees  infected. 

One  of  the  departments  where  the  disease  was  very  prevalent  in 


190  INDUSTRIAL   MEDICINE    AND    SURGERY 

the  author's  experience  had  a  number  of  employees  absent  for  this 
cause  during  the  first  two  weeks.  We  then  began  a  thorough  formal- 
dehyd  fumigation  of  this  department  every  night  with  the  result 
that  this  infection  decreased  materially  within  the  next  two  weeks, 
and  after  that  this  department  had  the  smallest  number  of  cases  com- 
pared with  the  other  departments  in  this  concern.  The  fumigation 
method  was  used  quite  extensively  after  the  first  month  of  the  epi- 
demic. Undoubtedly  two  sources  of  infection  can  be  controlled  by 
frequent  cleaning  and  fumigation,  namely,  the  material  handled  and 
the  dust  in  the  rooms. 

Physicians  in  industry  are  in  the  best  position  to  co-operate  with 
the  public  health  officials  in  controlling  these  epidemics  in  a  community. 
They  can  discover  many  of  the  cases  at  their  onset  and  start  early, 
proper  treatment.  They  can  educate  the  employees  as  to  the  best 
means  of  preventing  the  disease  and  its  spread  from  one  individual 
to  another.  The  entire  field  of  industrial  hygiene  can  be  utilized 
to  combat  the  epidemic  in  both  the  industries  and  in  the  community. 

The  above  description  of  the  streptococcic  epidemic  of  1915 
and  the  methods  employed  then  are  applicable  to  the  epidemics 
described  to-day  under  the  various  titles  of  "Spanish  influenza," 
influenza,  epidemic  of  streptococcus  pneumonia  and  empyema 
(Joseph  Miller),  epidemic  streptococcal  bronchopneumonia  (W.  G. 
MacCallum),  hemolytic  streptococcus  causing  severe  infections 
(H.  L.  Alexander),  and  described  by  Rufus  Cole  under  prevention  of 
pneumonia. 

Most  of  these  later  epidemics  have  been  reported  from  army 
camps  where  the  crowding  together  of  the  soldiers  has  facilitated 
their  spread.  But  the  same  epidemics  are  weakening  our  man  power 
in  industry  and  causing  an  ever  increasing  loss.  Every  year  it  is 
becoming  more  and  more  evident  that  the  physician  in  industry 
must  become  an  expert  epidemiologist  if  he  is  to  render  the  greatest 
services. 

While  authorities  differ  as  to  the  part  played  by  the  influenza 
bacillus  in  these  epidemics,  yet  most  investigators  are  convinced 
that  the  hemolytic  streptococcus  and  the  various  types  of  the  pneu- 
mococcus  were  the  most  dangerous  agencies  in  the  above  described 
epidemic. 

In  order  to  adequately  meet  the  situation  it  must  be  determined  to 
what  extent  the  influenza  organism  lowers  the  patient's  resistance  and 
makes  possible  the  invasion  of  these  streptococcus  organisms.  The 
profession  must  become  familiar  with  the  exact  nature  of  these 
hemolytic  streptococci  and  pneumococci  which  are  so  prevalent  in 
all  of  these  epidemics.  There  are  many  unknown  factors  which  must 
be  cleared  up  before  our  preventive  measures  can  be  fully  perfected. 


EPIDEMIOLOGY    IN    INDUSTRY  191 

It  is  just  as  necessary  therefore  for  every  industrial  dispensary 
to  have  a  well  equipped  laboratory  and  a  special  laboratory  worker 
to  study  this  disease  among  the  employees  as  it  is  to  have  a  similar 
arrangement  in  the  army  hospitals.  More  attention  must  be  paid  to 
the  scientific  field  of  investigation  of  diseases  among  employees.  The 
savings  to  industry  by  such  efforts  would  pay  a  hundred-fold  dividends. 

Until  we  know  the  different  strains  of  the  organisms  causing  these 
epidemics  our  best  preventive  measure,  namely  vaccination,  cannot 
be  perfected.  Nevertheless  good  reports  are  constantly  being  received 
which  point  to  the  fact  that  vaccination  against  pneumonia  will 
soon  be  perfected.  Lister,  in  South  America,  has  reported  very  decided 
results  from  vaccination  against  pneumonia  among  the  natives  working 
in  the  mines,  among  whom  pneumonia  has  always  been  very  fatal. 

The  isolation  of  these  cases  in  infectious  hospitals,  keeping  them 
segregated  from  other  non-infected  patients,  the  cubicle  system, 
and  other  methods  of  prevention  after  the  disease  is  established 
are  giving  excellent  results. 

Our  greatest  problem  both  in  industry  and  in  the  army  is  to 
prevent  the  spread  of  the  disease.  Searching  out  the  cases  instead 
of  waiting  for  them  to  seek  the  doctor,  instituting  early  isolation  and 
treatment,  educating  each  individual  in  methods  of  prevention  and  his 
responsibility  toward  others,  and  re-enforcing  the  methods  of  sanitation  in 
both  the  working  places  and  the  homes,  are  the  essential  elements  for  the 
control  of  epidemics. 

Searching  Out  the  Cases. — 1.  See  every  sick  employee,  take 
his  temperature  and  pulse,  examine  his  throat  and  in  other  ways 
ascertain  if  his  sickness  is  due  to  this  disease. 

2.  Instruct  nurses  and  lay  assistants  among  the  employees  (fore- 
men, assistant  foremen  and  intelligent  employees)  to  mingle  with 
the  working  force  and  pick  out  anyone  who  shows  prodromal  symptoms. 
Send  these  to  the  doctors  for  examination. 

Early  Isolation  and  Treatment. — 1.  Immediately  send  every 
employee  with  fever  of  99^°  or  with  a  "cold,"  sore  throat  or  other 
prodromal  symptoms  home.  It  is  better  to  have  ten  such  employees 
away  for  two  days  each  than  that  three  of  their  number  should  develop 
a  severe  infection  causing  two  weeks'  loss  of  time  for  each.  These 
mild  cases  often  are  the  sources  of  infection  for  other  employees  who 
may  lose  many  days  from  work. 

2.  Proper,  early  treatment  given  to  those  people  with  the  prodromal 
symptoms  will  abort  the  more  serious  infections  with  their  subsequent 
complications  in  the  majority  of  cases. 

3.  Rest  in  bed,  free  catharsis,  and  light,  nourishing  food  are  the 
most  essential  factors  in  early  treatment.  Each  case  should  be  super- 
vised so  that  a  doctor  is  called  at  the  first  indication. 


192  INDUSTRIAL   MEDICINE    AND    SURGERY 

4.  Protection  of  those  caring  for  these  cases  by  masks,  gowns, 
rubber  gloves  and  disinfectants  is  essential. 

Education  and  Individual  Prevention. — 1.  By  individual  con- 
ferences, talks  with  groups  of  employees,  bulletin  board  signs,  and 
large  placards  and  bulletins  printed  in  the  different  languages,  the 
employees  can  be  educated  in  all  matters  of  prevention  and  their 
responsibility  toward  fellow  employees. 
2.  The  chief  points  to  emphasize  are: 

(a)  Reporting  to  the  doctor  at  once  when  prodromal  symptoms 

are  noted.  (Describe  these.) 
(6)  Sources  of  spread  of  the  disease,  namely,  by  careless  sneezing, 
coughing,  blowing  of  the  nose,  breathing  or  talking  in  another's 
face,  using  common  drinking  cups  and  towels,  placing  things 
in  the  mouth  or  handling  articles  which  others  will  place  in 
their  mouths,  carelessly  shaking  the  handkerchief  about, 
promiscuous  spitting  and  numerous  other  ways  in  which 
the  infected  employee  can  become  a  menace  to  others. 

(c)  Avoiding  crowded  rooms,  theatres,  street  cars,  when  possible, 
and  other  places  where  people  tend  to  congregate. 

(d)  Instruct  in  home  sanitation  and  the  means  of  contaminating 
or  being  contaminated  by  other  members  of  the  family. 

(e)  Preach  good  food,  plenty  of  fresh  air,  and  sufficient  rest  at 
all  times. 

(/)  Avoid  booze,  keep  bowels  regular  and  establish  other  regular 
habits. 

(^f)  Report  every  suspicious  case  to  the  doctors  just  as  for  diph- 
theria or  small-pox. 
Reinforcing  Sanitation  Methods.^ — 1.  By  preventing  overcrowding. 

2.  By  adequate  ventilation  especially  frequent  airing  out  of  the 
rooms. 

3.  By  cleanliness  about  the  plant;  sweeping  only  at  night  and 
then  wet  sweeping. 

4.  By  some  adequate  form  of  fumigation. 

5.  By  rest  periods  and  other  means  of  avoiding  fatigue. 

6.  By  co-operating  with  the  Public  Health  officials. 

This  problem  of  the  acute  respiratory  infections  in  the  epidemic 
form  has  been  dealt  with  at  length  because  of  its  insidious  nature, 
the  great  damage  which  it  can  do  among  employees,  and  because  the 
methods  of  combating  it  also  apply  to  all  other  types  of  epidemics. 

Diphtheria 
Diphtheria  is  another  disease  which  requires  constant  alertness 
on  the  part  of  the  physician  in  industry  to  prevent  its  becoming 
epidemic.     Fortunately  it  can  usually  be  diagnosed  early  by  adequate 


EPIDEMIOLOGY    IN    INDUSTRY  193 

laboratory  methods.  The  discovery  of  a  few  cases  of  this  disease  by 
the  plant  laboratory  is  always  one  of  the  strongest  arguments  in 
favor  of  this  necessary  adjunct  to  a  well  equipped  doctor's  office. 

Every  employee  reporting  with  a  suspicious  throat  or  with  a  very 
marked  tonsillitis  should  be  sent  to  the  laboratory  for  an  immediate 
smear  examination  and  culture.  The  latter  can  be  sent  to  the  City 
Health  Department  if  facilities  are  lacking  for  incubation.  All  these 
suspicious  cases  should  be  sent  home  at  once.  When  the  smear 
shows  diphtheria  bacilli,  the  same  should  be  reported  to  the  family 
physician  direct  so  that  he  can  administer  the  antitoxin  early.  Just 
as  soon  as  the  report  is  obtained  from  the  culture  it  should  also  be 
reported  if  positive.  All  of  these  cases  must  be  reported  to  the  Health 
Department  of  the  community  at  once  so  that  proper  quarantine 
measures  can  be  provided. 

The  department  where  the  case  developed  must  be  closely  watched 
for  any  other  signs  of  an  outbreak.  All  employees  who  remain  at 
home  on  account  of  sickness  during  the  next  ten  days  should  be  visited 
by  the  nurse  and  the  cause  of  the  absence  ascertained.  The  foreman 
and  assistant  foreman  should  always  be  advised  of  the  condition  and 
their  co-operation  secured  for  a  closer  observance  of  the  existing  rules 
if  this  is  possible.  "Whenever  a  case  of  diphtheria  develops  at  the 
plant  the  department  should  be  thoroughly  fumigated  as  soon  as  the 
employees  leave  at  night.  The  watchman  can  throw  open  the  windows 
about  4  A.M.  and  air  out  the  room  before  the  force  arrives  in 
the  morning. 

These  rules  have  been  carefully  enforced  by  the  author  for  several 
years.  Many  cases  of  diphtheria  have  been  found  among  the  em- 
ployees but  seldom  has  it  spread  from  one  employee  to  another.  The 
nearest  approach  to  an  epidemic  was  when  seven  girls  in  one  depart- 
ment developed  the  disease  at  the  same  time.  Two  of  these  girls  who 
roomed  together  failed  to  report  for  work  because  they  were  sick. 
The  nurse  called  and  found  that  no  doctor  had  been  consulted  although 
both  girls  had  severe  sore  throats.  Cultures  were  made  by  the  nurse 
and  brought  to  the  laboratory.  The  next  morning  these  were  found 
to  be  positive  for  diphtheria.  The  nurse  immediately  called  and  had 
the  girls  send  for  their  physician  who  took  charge.  The  health  depart- 
ment was  also  notified.  That  day  two  other  girls  from  this  same  de- 
partment reported  to  the  doctor's  office  with  suspicious  throats  and 
cultures  proved  positive  in  both  cases.  The  department  was  fumigated 
that  night.  Every  girl  who  was  absent  during  the  next  ten  days  was 
visited  by  a  nurse  and  the  three  additional  cases  were  discovered  in 
this  way.  Without  the  help  of  the  laboratory  I  am  convinced  that  a 
real  epidemic  of  diphtheria  would  have  developed  in  this  department 
where  200  girls  were  employed. 

13 


194  INDUSTRIAL    MEDICINE    AND    SURGERY 

Time  and  again  the  public  health  department  has  been  put  in  touch 
with  these  sources  of  contagion  and  has  been  able  to  stamp  out  a 
threatened  epidemic  in  the  community. 

The  Acute  Exanthemata 

Sporadic  cases  of  measles,  scarlet  fever,  mumps,  chicken-pox,  and 
other  contagious  diseases  are  more  or  less  prevalent  in  all  communities. 
These  diseases  appear  at  intervals  among  the  employees  of  any  large 
industry.  Constant  watchfulness  is  necessary  to  prevent  their 
becoming  epidemic  among  those  employees  who  are  working  in  close 
contact  with  one  another.  This  watchfulness  must  be  increased  when- 
ever these  diseases  appear  in  epidemic  proportions  in  the  community. 

In  order  to  combat  these  contagious  diseases  among  employees  the 
physician  must  have  accurate  knowledge  of  every  sign  and  symptom, 
must  be  able  to  discover  these  in  their  earliest  aspects,  and  must  iso- 
late all  such  cases  at  once.  Following  this  the  constant  supervision 
of  the  other  employees  from  that  department  and  the  fumigation  of 
the  department  must  be  carried  out  as  described  for  diphtheria.  The 
visiting  nurse  is  the  greatest  ally  the  physician  has  in  all  of  these  cases. 
Reports  from  the  city  health  departments  can  be  obtained  whenever  a 
contagious  disease  is  present  in  the  homes  of  any  of  the  employees, 
thus  enabling  the  physician  to  give  individual  supervision  to  such 
workmen. 

In  a  large  industry  employing  15,000  people  in  Chicago,  the  follow- 
ing contagious  cases  were  found  during  a  period  of  six  months.  Mumps 
alone  appeared  in  epidemic  form  and  was  under  control  after  one 
month. 

Disease      '                                                                                                               Number  of  cases. 
Mumps 22 

5  cases  in  one  department 
4  cases  in  one  department 

6  cases  in  three  departments 

7  cases  in  seven  departments 

Scarlet  Fever 9 

2  cases  in  one  department 

7  cases  in  seven  departments 
Diphtheria 6 

2  cases  in  one  department 

2  cases  in  one  department 

2  cases  in  two  departments 
Measles 4 

4  cases  in  four  departments 
Erysipelas , 2 

2  cases  in  two  departments 

Chicken-pox 1 

Total 44 


EPIDEMIOLOGY    IN    INDUSTRY  195 

The  small  number  of  these  cases  occurring  in  the  same  department 
proves  the  advantage  of  this  system  of  supervision.  Every  one  of 
these  employees  were  potential  epidemic  breeders. 

Small-pox.^ — ^Most  large  industries  require  a  certificate  of  vaccina- 
tion from  every  new  employee.  Some  concerns  vaccinate  free  of 
charge  all  applicants  who  fail  to  show  a  good  scar  or  who  have  not  been 
vaccinated  within  the  last  seven  years.  This  latter  plan  was  followed 
for  three  years  in  the  concern  with  which  the  author  was  connected. 
It  was  seldom  that  a  new  employee  refused  to  be  vaccinated.  Any 
arms  that  became  quite  sore  or  infected  were  cared  for  free  of  charge 
the  same  as  an  accident  case,  the  employee  receiving  full  wages  during 
his  absence.  This  took  much  valuable  time  from  the  other  medical 
work  and  was  finally  abandoned.  Only  those  cases  who  on  examina- 
tion could  not  show  a  good  vaccination  scar  were  required  to  be  vac- 
cinated before  being  employed. 

Twice  during  a  period  of  nine  years  the  entire  working  force  has 
been  vaccinated  because  of  a  case  of  small-pox  developing  in  an  em- 
ployee whUe  at  work.  Two  doctors  with  four  nurses  as  assistants  were 
able  to  vaccinate  3000  employees  a  day,  thus  protecting  the  entire 
force  by  this  method  within  a  period  of  five  days.  In  both  instances 
the  president  and  general  manager  of  this  concern  set  the  example  by 
being  vaccinated  first. 

Supervision  of  the  working  force,  co-operation  with  the  city  health 
department  and  vaccination  are  the  preventive  measures  needed 
against  small-pox. 

Typhoid  Fever. — This  disease  has  often  proven  very  disas- 
trous to  working  forces.  The  chief  methods  of  prevention  consist 
of  proper  sanitation  in  the  working  force  and  in  the  community. 
Typhoid  was  very  prevalent  among  the  lumbermen  of  the  Northwest. 
The  industrial  surgeons  of  Washington  inaugurated  an  educational 
campaign  against  it  which  aimed  at  the  employers  and  employees 
alike.  By  improving  the  privies  and  providing  other  means  for  sew- 
age disposal  and  by  educating  the  people  as  to  means  of  prevention, 
they  were  able  to  reduce  typhoid  fever  to  a  wonderful  extent.  The 
sanitation  measures  necessary  to  prevent  this  disease  are  so  well 
known  that  details  are  not  necessary  here.  Every  physician  in  in- 
dustry should  make  it  his  business  to  clean  up  all  conditions  in  the 
plant  or  in  the  community  which  predispose  to  this  disease  (see  Figs. 
23  and  24). 

The  experiences  in  the  army  of  preventing  typhoid  fever  by 
inoculation  have  proven  how  efficacious  this  method  is.  Only 
one  death  in  almost  2,000,000  inoculations  has  been  attributed 
to  this  measure.  So  far  there  has  been  less  than  100  cases  of 
typhoid  fever  in  the   army   since  this   war  began.     Mark  the  con- 


196  INDUSTRIAL    MEDICINE    AND    SURGERY 

trast  in  the  army  during  the  Spanish-American  War  when  at 
times  90  per  cent,  of  the  cases  in  the  hospitals  were  due  to  this 
disease. 

Undoubtedly  our  civilian  population  will  adopt  this  form  of  pre- 
vention as  universally  as  they  have  vaccination  against  small-pox. 
The  physicians  in  industry  should  provide  inoculations  against  typhoid 
for  all  employees  who  voluntarily  seek  this  form  of  prevention. 

Several  things  are  very  essential  in  dealing  with  contagious  diseases 
among  the  employees.  Common  sense  methods  must  be  used  which 
will  yield  proper  protection  for  the  entire  working  force  and  yet  will 
not  cripple  or  stop  the  production  of  the  plant  entirely.  For  example, 
when  a  case  of  scarlet  fever  is  found  in  a  department  it  would  afford 
a  greater  measure  of  safety  perhaps  to  at  once  dismiss  the  rest  of  the 
force  and  fumigate  the  department  at  once.  Such  a  procedure  would 
be  disastrous  to  business  and  fumigation  at  night  with  the  other  pre- 
cautionary measures  described  have  proven  adequate.  Every  effort 
must  also  be  made  to  avoid  panics  among  the  other  employees.  A 
cool,  calm,  matter  of  fact  attitude  toward  the  situation  will  allay 
fears  among  the  timid  ones  whereas  excitement,  blustering  or  a  dis- 
play of  haste  will  often  start  a  panic.  I  have  taken  smears  from 
the  throat  of  every  employee  in  a  department  looking  for  diphtheria 
carriers  without  creating  the  least  fear  among  them.  Careful  explana- 
tions of  your  reasons  for  doing  thus  and  so  will  always  result  in  co- 
operation from  the  working  force. 

The  doctor's  office  should  be  provided  with  a  room  where  these  con- 
tagious cases  can  be  isolated  while  awaiting  transportation  home  or 
to  the  hospital.  They  should  never  be  allowed  to  go  home  on  the 
street  car  or  in  public  conveyances.  The  writer  made  arrangements 
with  a  taxicab  company  to  take  such  cases  home  and  then  have  the 
cab  return  for  fumigation.  It  is  our  duty  to  make  sure  that  all 
public  cabs  used  by  contagious  cases  are  properly  fumigated  before 
accepting  other  passengers.  Often  the  public  health  departments 
will  furnish  free  transportation  in  an  ambulance  for  all  contagious 
cases. 

No  greater  opportunity  for  developing  the  most  scientific  epidemio- 
logical methods  can  be  found  than  here  in  the  practice  of  Industrial 
Medicine.  All  the  involved  economic  and  social  problems  are  here 
combined  with  our  medical  efforts. 

Venereal  Diseases 

The  combating  of  venereal  disease  among  employees  has  been  woe- 
fully neglected  by  the  majority  of  physicians  in  industry.  This  can 
be  accounted  for  in  two  ways:  (1)  The  indifferent  attitude  which 


EPIDEMIOLOGY   IN   INDUSTRY  197 

the  medical  profession  has  always  assumed  toward  the  prevention  of 
these  diseases;  (2)  the  fact  that  most  concerns  have  discharged  the 
employee  who  was  discovered  with  venereal  disease. 

The  war  has  awakened  the  profession  and  the  general  public  to 
the  extensiveness  and  the  ravages  of  both  gonorrhea  and  syphilis 
throughout  the  army  and  the  civil  population.  It  is  to  be  expected 
that  a  more  active,  nationwide  fight  against  these  conditions  will  be 
the  result.  The  plant  physicians  are  in  the  best  position  to  take  a 
very  prominent  part  in  such  an  effort. 

Figures  obtained  from  many  industrial  physicians  show  that  the 
number  of  venereal  cases  found  among  the  employees  examined  varies 
from  2  to  10  per  cent.  This  is  exceedingly  low  as  compared  with 
other  diseases  found  and  as  compared  with  the  statistics  given  showing 
the  great  prevalence  of  these  diseases  in  the  army  and  in  many  of  our 
large  cities.  The  explanation  is  found  in  the  fact  that  the  infected 
employee  very  carefully  concealed  his  trouble  fearing  the  loss  of  his 
job  if  it  became  known. 

In  1915  I  began  a  systematic  search  for  these  cases.  The  manage- 
ment, through  their  medical  department,  let  it  become  known  that  no 
man  would  lose  his  job  if  he  reported  to  the  doctor's  office  when  he 
was  diseased  and  especially  if  he  followed  the  directions  given  him  re- 
garding the  protection  of  others.  As  a  result  the  number  of  men  found 
with  venereal  diseases  rapidly  increased.  Arrangements  were  made 
to  treat  all  these  cases  at  the  night  clinic  of  Industrial  Medicine  and 
Surgery  at  Rush  Medical  College.  Salvarsan  was  administered  to  the 
syphilitic  cases  for  the  cost  of  the  drug.  In  a  few  cases  loans  from 
the  concern  were  made  to  buy  this  drug  due  to  the  fact  that  it  became 
very  expensive  during  the  early  years  of  the  war.  All  employees  with 
syphilis  in  its  communicable  stage  were  kept  away  from  work  until 
the  open  lesion  was  healed.  Careful  instructions  were  given  to  aU 
types  of  cases  regarding  the  dangers  of  contaminating  others.  The 
acute  gonorrheas  were  given  light  work  always  until  it  was  safe  for 
them  to  return  to  heavy  occupations. 

Prevention  propaganda  was  spread  by  personal  talks  whenever 
possible.  I  am  sorry  to  admit  that  a  general  campaign  of  preven- 
tion against  this  condition,  which  certainly  lowered  the  efficiency  of 
the  working  force  and  caused  much  loss  of  time  from  work,  was  not 
undertaken. 

It  is  absolutely  necessary  for  the  medical  staffs  of  industry  to 
at  once  recognize  that  the  prevention  of  venereal  diseases  is  as  logical 
a  part  of  their  work  as  the  prevention  of  accidents  and  of  other  diseases. 

To  accomplish  this  they  should  immediately  adopt  the  following 
procedures : 

1.     Spread  the  propaganda  concerning  the  prevention  of  venereal 


198  INDUSTRIAL   MEDICINE    AND    SURGERY 

diseases  throughout  the  entire  force,  by  posters  printed  in  different 
languages  and  placed  in  every  toilet;  by  individual  talks,  lectures  to 
the  men  and  stereopticon  shows;  b}'-  women  physicians  giving  lectures 
to  the  girl  employees.  The  following  bulletin  taken  from  the  State 
Board  of  Health  of  Michigan  and  adapted  to  industrial  needs  by  a 
few   changes  will   illustrate  the  type  of  poster  to  use: 

VENEREAL  DISEASES 

"Gonorrhea  (or  clap)  is  a  germ  disease.  It  causes:  (1)  111 
health  and  loss  of  time  and  money  to  the  man  infected.  (2)  Many 
innocent  wives  to  become  invalids  for  life.  (3)  A  large  proportion 
of  surgical  operations  upon  women.  (4)  Many  childless  marriages. 
(5)  Much  of  the  blindness  of  children.  Gonorrhea  can  be  cured 
but  often  is  not  cured  when  the  man  thinks  himself  cured.  The  germs 
of  gonorrhea  often  remain  hidden  in  the  body  ready  to  cause  serious 
trouble,  even  when  the  symptoms  of  disease  have  apparently  ceased 
under   treatment. 

"  Syphilis  (or  pox)  is  often  a  germ  disease.  If  not  cured,  syphilis 
may  be  transmitted  to  wives  and  children  many  years  after  infection. 
It  may  cause  insanity,  locomotor  ataxia,  or  total  paralysis.  Syphilis 
can  be  cured,  but  only  by  long  and  thorough  medical  treatment. 

"  Prevention. — (1)  Keep  away  from  prostitutes,  both  professional 
and  non-professional.  (2)  Sexual  intercourse  is  not  necessary  to  phys- 
ical and  mental  health.  (3)  Antiseptic  washes  and  other  preventive 
measures  are  not  always  reliable. 

"  Beware  of  advertising  specialists,  who  claim  to  cure  'nervous 
debility,'  and  'private  diseases  of  men."  The  use  of  patent  venereal 
medicines  may  lead  to  very  serious  consequences.  Night  emissions, 
or  'wet  dreams,'  if  not  too  frequent  are  natural  in  men.  They  are 
not  a  sign  of  'lost  manhood.'  Advertising  specialists  get  large  sums 
of  money  for  treating  'diseases'  which  do  not  exist. 

"  What  to  Do.- — (l)  If  you  have  exposed  yourself,  go  at  once 
to  a  competent  physician.  (2)  If  you  contract  venereal  disease  protect 
yourself  and  protect  others — report  at  once  to  the  doctor's  office. 
The  plant  physician  will  see  that  you  receive  proper  treatment. 
You  will  not  lose  your  job  and  the  trouble  wiU  be  held  confidential 
between  you  and  the  doctor.  (3)  Do  not  worry.  Lead  a  vigorous, 
healthful  life  and  forget  about  sex  matters.  (4)  Be  consistent 
and  adopt  the  same  standard  of  sexual  conduct  for  yourself  that  you 
expect  of  women." 

2.  Arrange  for  the  proper  treatment  of  every  venereal  case  and 
carefully  supervise  until  cured. 

3.  Instruct  each  case  in  proper  methods  of  protection  of  his 
fellow  workmen. 


EPIDEMIOLOGY    IN    INDUSTRY  199 

4.  Report  every  case  to  the  Department  of  Health  and  co-operate 
with  them  in  tracing  down  the  source  of  the  infection  and  in  freeing 
the  community  of  that  prostitute. 

5.  Subtly  ascertain  if  the  infected  employee  has  infected  other 
women  and  report  these  to  proper  authorities. 

6.  Work  for  the  adoption  by  all  state  governments  of  the  following 
measures  suggested  by  the  Council  of  National  Defense,  Committee 
for   Civilian   Co-operation    in   Combating    Venereal    Disease. 

"(a)  Establishment  of  a  Bureau  or  Division  of  Venereal 
Diseases  of  the  Department  of  Health  with  an  ade- 
quate personnel,  and  with  provisions  for  free  labora- 
tory examinations  (including  the  "Wassermann  test) 
and  for  the  distribution  of  arsphenamine  (salvarsan) 
under  proper  regulations  free  or  at  cost. 
"(6)  Provision  for  the  suppression  of  prostitution,  for  the 
examination  of  arrested  prostitutes  and  for  the  iso- 
lation and  treatment  in  public  institutions  of  those 
infected. 
"(c)  Provision  for  the  commitment  to  institutions  of  unin- 
fected prostitutes  for  industrial  training  and  for  the 
commitment  of  all  feeble-minded  prostitutes  to  cus- 
todial care. 
"(d)  Provision  for  the  reporting  of  syphilis  and  gonococcus 
infection  by  physicians  (according  to  regulations  which 
protect  both  the  patient  and  the  public),  and  for  the 
compulsory  and  systematic  treatment  of  all  infected 
persons  when  necessary  and  for  the  protection  of  the 
public  health. 
"(e)  Establishment  of  venereal   disease  clinics  and  advisory 

stations. 
"(f)  Provision  for  the  posting  of  venereal  disease  placards  in 
men's  lavatories  of  barber  shops,  Y.  M.  C.  A.'s,  hotels, 
railroad  stations,  factories,  stores  and  similar  places 
and  for  the  distribution  of  pamphlets  of  information. 
"(g)  Provisions  for  lectures   (with   or  without   stereopticon) 
and  for  the  display  of  educational  exhibits  under  the 
auspices  of  the  board  of  health,  the  council  of  defense 
or  other  agency,  before  business  men's  organizations, 
employed  men,  women,  boys,  and  girls,  church  organ- 
izations, women's  clubs  and  other  groups. 
"  (i^)  Provisions  for  the  elimination  of  advertising  specialists 
in  men's  diseases  and  of  the  sale  of  venereal  disease 
nostrums." 


200  INDUSTRIAL   MEDICINE    AND    SURGERY 

Industrial  surgeons  have  taken  the  lead  in  almost  every  branch  of 
preventive  medicine  and  preventive  surgery.  The  prevention  of 
venereal  diseases  alone  has  been  neglected.  Laying  all  other  motives 
aside,  from  an  economic  standpoint  we  can  no  longer  afford  to  neglect 
this  work. 


CHAPTER  XIX 
HEALTH  HAZARDS  IN  OCCUPATIONS 

The  physician  responsible  for  the  human  maintenance  in  an  in- 
dustry must  become  expert  in  the  detection  and  prevention  of  every 
health  hazard  connected  with  the  various  occupations  represented 
therein. 

Volumes  have  been  written  on  this  subject  of  occupational  diseases. 
In  Europe  numerous  laws  have  been  enacted  for  the  prevention  of  work 
diseases  and  of  recent  years  have  been  vigorously  enforced.  In  our 
own  country  the  various  states  are  beginning  to  awaken  to  their  re- 
sponsibility toward  the  millions  of  people  employed  in  hazardous 
occupations  and  each  year  sees  new  and  better  legislation  on  this  sub- 
ject. Not,  however,  until  clear  and  adequate  laws  are  passed  and 
rigidly  enforced  by  every  state  and  by  the  Federal  Government  wiU 
the  prevention  of  these  conditions  be  perfected.  Hand  in  hand  with 
the  legal  measures  there  must  be  a  nationwide  educational  campaign 
instituted. 

Physicians  practicing  industrial  medicine  must  know  the  classical 
occupational  diseases  and  must  be  constantly  on  the  lookout  for 
hazards  in  other  occupations  not  heretofore  considered  harmful  to 
employees.  These  doctors  must  become  the  pioneer  crusaders  in 
this,  one  of  the  greatest  health  movements  thus  far  undertaken  in  our 
country. 

Until  within  the  last  ten  years  the  subject  of  occupational  diseases 
has  been  woefuUy  neglected  by  the  majority  of  the  medical  profes- 
sion. As  a  result  of  the  work  of  a  few  physicians  in  industry  the  sub- 
ject has  been  more  and  more  forcibly  presented  with  the  end  that  at 
least  six  medical  schools  of  the  country  now  have  courses  for  the  stu- 
dents covering  many  of  these  diseases. 

Dr.  John  D.  Ellis,  one  of  the  pioneer  teachers  in  Industrial  Medi- 
cine at  Rush  Medical  College,  University  of  Chicago,  has  written 
the  following  article  on  Health  Hazards  in  Occupations  for  the  author. 
This  resume  and  the  references  to  other  authors  should  give  the  student 
an  excellent  insight  into  the  wide  range  of  diseases  which  can  result 
from  occupations  and  the  various  methods  employed  thus  far  for  their 
prevention. 

For  this  most  helpful  contribution  the  author  desires  once  more  to 
express  his  gratitude  to  his  co-laborer,  Dr.  John  D.  Ellis, 

201 


202 


INDUSTRIAL   MEDICINE    AND    SURGERY 


DUST  AS  A  HEALTH  HAZARD 

The  number  of  men  who  are  unfitted  for  work  at  their  trades  or 
who  are  incapacitated  after  a  few  years  of  work  because  of  conditions 
resulting  from  working  at  dusty  occupations  far  exceeds  those  incapa- 
citated by  all  other  health  hazards.  Dusty  trades,  therefore,  claim 
consideration  of  first  magnitude  by  the  industrial  physician.  The 
health  hazard  resulting  from  dusty  occupations  is  difficult  to  estimate 
since  injurious  effects  are  not  always  due  to  dust  itself,  but  many 
times  to  bacteria  gaining  entrance  to  the  system  with  the  dust,  or  to 
infections  made  possible  through  lowering  of  the  general  or  local 
resistance  caused  by  the  effect  of  dust  on  the  workmen. 

Dust,  both  of  the  invisible  and  visible  type,  is  much  more  dense  in 
the  air  in  factories  and  workshops  than  in  any  other  place  in  which 
human  beings  are  crowded  together.  The  coarser  dusts  are  of  course 
visible,  but  the  finely  pulverized  particles  of  matter  constituting  in- 
visible dust  may  be  far  more  harmful  if  composed  of  irritating  me- 
chanical matter  like  silicate  spicules  or  poisonous  material  such  as 
soluble  lead  salts. 

Some  of  the  commonest  industries  in  which  the  worker  inhales 
large  amounts  of  dust  are  the  textile  mills,  especially  cotton  mills,  in 
the  carding  and  preparing  rooms  and  manufacturing  of  shoddy,  in 
handling  of  rags  and  other  waste  products  of  such  mills,  manufactur- 
ing of  clothing  and  furs,  renovating  clothing,  rags  and  mattresses, 
in  flour  and  corn  mills,  quarrying  and  grinding  of  stone  and  the 
manufacture  of  cement,  the  smelting,  buffing  and  refining  of  metals, 
and  in  the  manufacture  of  carborundum,  graphite,  carbide  and  lime. 

Rambousek '  quotes  Hesse  whose  table  of  amounts  of  dust  inhaled 
by  men  working  ten  hours  a  day  in  certain  dusty  industries  is  as 
follows : 


Horsehair  works 0 .  05  grams  per  day 

Saw  mills 0.09  grams  per  day 

Wool  mills. 0. 10  grams  per  day 

Flour  mills 0. 12  grams  per  day 

Iron  foundries 0. 14  grams  per  day 

Snuff-tobacco  workers 0 .  36  grams  per  day 

Cement  works 1.12  grams  per  day 


15  grams  per  year  (300  days) 

27  grams  per  year 

30  grams  per  year 

36  grams  per  year 

42  grams  per  year 
108  grams  per  year 
336  grams  per  year 


Arens^  determinations  show  that  in  cement  works  while  not 
in  operation  there  were  130  milligrams  of  dust  per  cubic  meter; 
while  during  the  operation  of  the  plant  there  were  244  milligrams. 
In  a  felt  shoe  factory  in  operation  he  estimated  there  were  175  milli- 
grams of  dust  per  cubic  meter  of  air;  while  Rogers  found  in  skirt  fac- 


1  Luftnerungreinigung  und  Ventilation,  p.  103. 

2  Ibid. 


HEALTH  HAZARDS  IN  OCCUPATIONS  203 

tory  and  pearl  button  works  70  grams  of  dust  per  million  liters  of  air 
and  in  a  brass  foundry  75.2  grams  in  the  same  volume  of  air. 
Price ^  classifies  dust  as  follows: 

1.  As  to  source: 

(a)  Meta  . 

(b)  Mineral. 

(c)  Vegetable. 

(d)  Animal. 

2.  As  to  physical  qualities: 
(a)  Size. 

(6)  Shape. 

Round  or  sharp  edges. 

3.  As  to  chemical   characteristics: 
(a)  Organic   or  inorganic. 

(6)  Soluble   or   insoluble. 

Hoffman^  classifies  the  source  of  dust  in  forty-two  dusty  industries, 
which  of  course  does  not  include  entire  category,  into  the  following 
groups : 


<UJ 

)  1. — Exposure  to  metallic  dust 

Group  2. — Exposure  to  mineral  dust 

1. 

Grinders 

11.  Stone  workers 

2. 

Polishers 

12.  Marble  workers 

3. 

Tool  and  instrument  makers 

13.  Glass  blowers 

4. 

Jewelers 

14.  Diamond  cutters 

5. 

Gold  leaf  manufacture 

15.  Glass  cutters 

6. 

Brass  workers 

16.  Potters 

7. 

Printers 

17.  Cement  workers 

8. 

Compositors 

18.  Plasterers 

9. 

Pressmen 

19.  Paper  hangers 

0. 

Engravers 

20.  Molders 

21.  Coremakers 

22.  Lithographers 

Group  3. — Exposure  to  vegetable  fiber  dust 

23.  Cotton  ginning  29.  Flax  and  linen  manufacture 

24.  Cotton  textile  manufacture  30.  Hemp  and  cordage  manufacture 

25.  Spinners  31.  Manufacture  of  jute  and  jute  goods 

26.  Weavers  32.  Paper  manufacture 

27.  Hosiery  and  knitting  mills  33.  Cabinet  makers 

28.  Lace  making  34.  Wood  turners  and  carvers 

Group  4. — Exposure  to  animal  and  mixed  fiber  dust 

35.  Furriers  and  taxidermists  39.  Carpet  and  rug  manufacture 

36.  Hatters  40.  Shoddy  manufacture 

37.  Silk  manufacture  41.  Rag  industry 

38.  Woolen  and  worsted  manufacture  42.  Upholstery  and  hair  mattress  makers 

1  Modern  Factory,  p.  395. 

2  United  States   Department  of  Labor,  Bulletin  79,  Mortality  from  Consump- 
tion in  Dusty  Trades. 


204  INDUSTRIAL   MEDICINE    AND    SURGERY 

Migerka^  has  made  a  thorough  study  of  the  shapes  of  dust  particles 
and  crystals,  and  other  various  injurious  effects  on  the  lining  of  the  res- 
piratory passages.  He  has  collected  microphotographs  of  the  various 
dust  particles. 

Pathological  Effects  of  Dust  Inhalation. — Thompson^  divided  effects 
of  dust  on  the  human  system  into  four  types: 

1.  Mechanical  obstruction  of  air  passages.  When  the  respiratory 
passages  are  in  normal  condition  1  per  cent,  of  the  dust  is  collected 
by  the  mucosa  of  the  nose  and  throat  before  it  reaches  the  larynx. 
Heim  and  Hebert^  have  made  a  study  of  the  effect  of  plaster-of-Paris 
dust  on  rabbits  and  dogs  and  find  that  but  few  inhaled  particles  pass 
the  vocal  cords.  Ghrorer^  has  shown  more  than  50  per  cent,  of 
lead  dust  inhalations  is  caught  in  the  nasal  passages  while  the  mouth 
shows  as  high  as  15  per  cent,  of  the  inhaled  dust.  Glogau^  ex- 
amined a  number  of  workers  in  the  jute  mills  and  artificial  flower 
and  feather  shops,  finding  that  the  nose  was  sometimes  entirely  filled 
with  dust  while  in  others  only  the  turbinates  and  septum  were  affected. 

2.  Laceration  of  the  delicate  mucous  epithelium.  The  effects 
of  dust  on  the  respiratory  mucosa  vary  in  degree  from  irritating 
reflexes  such  as  sneezing  and  coughing,  and  increased  lacrimation 
with  subacute  or  chronic  congestion  of  the  mucous  membrane  through 
aU  degrees  of  catarrhal  rhinitis,  laryngitis  and  bronchitis,  depend- 
ing on  what  bacterial  invaders  appear  in  the  field  where  the  resistance 
of  the  tissues  has  been  lowered  by  the  constant  assault  by  dust  parti- 
cles. In  the  lungs  all  stages  of  inflammation  from  mild  bronchitis 
to  chronic  fibroid  changes,  pneumonia  or  phthisis  can  result.  An 
anaphylactic  reaction  may  result  from  inhalation  of  animal  or  plant 
dust  and  a  part  at  least  of  the  occupational  asthmas  are  set  up  by 
this  mechanism.  Arnold,^  has  placed  animals  in  atmosphere  with 
some  sandstone  and  ultramarine  dust.  All  these  types  of  dust  reach 
the  lung  tissue  easily  and  were  found  in  the  alveoli  in  the  lung  cells. 
There  is  a  great  divergency  in  the  amount  of  harm  done  by  the  different 
particles  of  dust  and  this  depends  chiefly  on  the  size,  shape,  character 
and  mechanical  action  of  the  particles.  It  is  generally  considered 
that  of  the  mechanical  irritants,  silica  is  the  most  injurious.  All 
metal  and  mineral  dusts  are  more  harmful  than  organic  vegetable  or 

1  Monograph  on  the  Kinds  of  Dust  in  Industrial  EstabUshments  from  the 
Museum  of  Industrial  Hygiene  of  Vienna. 

2  "Occupational  Diseases,"  1914,  p.  42. 

3  Effects  of  Dust  in  Producing  Disease  of  the  Lungs.  Lecture  before  the  17th 
International  Congress  of  Medicine,  London,  1913,  p.  21. 

*  "Orientierende  Versuche  uber  Quantitative  Staub-absorption  durch  den 
Menschem  aus  staubreicher  Luft,"  Wurzburg,  1912,  p.  22. 

6  Second  Report  of  New  York  State  Factory  Commission,  Vol.  II,  p.  537. 
®Ascher:  "Damer's  handbuch  Der  Arbeiter  Wohlfahrt, "  p.  410. 


HEALTH  HAZARDS  IN  OCCUPATIONS 


205 


animal  dust  unless  the  latter  carry  infectious  material  with  them. 
Dust  of  emery,  glass,  granite,  etc.,  has  a  very  curious  mechanical 
action.  Dr.  CoUis^  concludes  that  inhalation  of  all  types  of  dust 
mechanically  diminishes  the  power  of  chest  expansion  through  the 
production  of  interstitial  lung  changes  and  subsequent  emphysema. 
This  diminution  is  later  accompanied  by  high  blood  pressure.  He 
thinks  vegetable  dusts  are  usually  liable  to  produce  asthma.  He 
considers  that  of  the  mineral  dusts,  calcium  salts  are  the  least  injurious, 
and  that  those  not  containing  free  silica  tend  to  produce  irritation 
of  the  upper  air  passages  and  non-tuberculous  lung  diseases,  whereas 
others  containing  free  silica  are  more  likely  to  produce  tuberculosis. 

3.  Conveyance  of  soluble  toxic  material  into  the  system.  A  well 
known  example  of  this  is  the  general  effects  of  lead  poison  resulting 
from  inhalation  of  lead  dust  in  the  painting  and  smelting  trades. 

4.  Conveyance  of  germs  in  dust.  Rambousek  well  says,  "Where 
no  dust  is,  there  are  no  bacteria  in  the  air." 

THE  CHIEF  DUSTY  TRADES 

In  Hoffman's^  estimate  based  on  United  States  Census,  1910, 
of  44,130,000  American  workers  of  both  sexes,  probably  5,600,000 
or  about  12.5  per  cent,  are  exposed  to  a  greater  or  less  degree  to  the 
health  hazard  due  to  working  in  an  atmosphere  containing  a  "rela- 
tively excessive  presence"  of  atmospheric  impurities  coming  under  the 
classification  of  dust.  He  has  adopted  a  division  of  dusty  trades 
depending  upon  the  composition  of  dust  to  which  the  worker  is  most  ex- 
posed, i.e.,  metal,  mineral,  vegetable  fiber,  animal  and  mixed  fiber  dust, 
and  this  makes  as  good  a  basis  as  any  other  for  the  discussion  of  some  of 
the  industrial  processes  involving  the  greatest  health  hazard  due  to  dust. 

NUMBER  OF  PERSONS  ENGAGED  IN  OCCUPATIONS  MORE  OR 
LESS  EXPOSING  TO  INJURIOUS  DUSTS,  GASES  OR  FUMES, 
IN  THE  UNITED  STATES 
(Ages  10  Years  and  Over) 


Exposure  to 


Males. 


Females 


Persons 


Metallic  dust 

Mineral  dust 

Animal  and  mixed  fiber  dust. 

Vegetable  fiber  dust 

General  organic  dust 

Municipal  dust 

Gas  exposure,  fumes,  etc 


847,689 
756,459 
638,997 
152,999 
500,936 
702,251 
1,196,191 


Total. 


4,795,522 


45,387 

16,424 
494,505 

22,467 

214,325 

180 

19,954 


813,152 


893,076 
772,883 

1,133,502 
175,466 
715,171 
702,431 

1,216,145 


5,608,674 


1  A.  L.  Collis:  "Effects  of  Dust  Producing  Lung  Diseases." 

2  U.  S.  Department  of  Labor  Bulletin  79. 


206  INDUSTRIAL    MEDICINE    AND    SURGERY 

Metallic  dust  exists  to  an  injurious  extent,  in  the  atmosphere 
in  almost  every  place  in  which  metals  are  mined,  smelted,  refined, 
are  manufactured  into  machinery  or  other  finished  products.  Hoff- 
man^ cites  as  evidence  of  the  deleterious  effects  of  metallic  dust  in- 
halation in  the  metal  trades,  the  fact  that  a  relatively  small  number 
of  persons  of  advanced  years  work  in  these  industries ;  relatively  high 
death  rate  prevails  as  compared  with  other  trades,  and  more  espe- 
cially a  high  rate  of  death  from  diseases  of  the  lungs.  In  foundries  the 
greatest  amount  of  dust  is  evolved  during  the  casting  and  baking  of 
cores,  grinding  cast  objects  and  in  the  sand  blasting  processes.  Grind- 
ing, poHshing,  and  buffing  metal  cast  objects  or  metal  dies  evolves 
both  metallic  dust  and  mineral  dust  from  the  grinding  wheel.  The 
most  dangerous  metallic  dusts  are  those  composed  of  brass,  copper, 
and  lead,  since  these  act  not  only  as  mechanical  irritants  to  the 
respiratory  system  and  eyes  but  by  absorption,  in  the  case  of  lead 
at  least,  also  to  constitutional  poisoning. 

Mineral  dust  abounds  as  mentioned  above  wherever  dry  grinding 
occurs  and  also  in  all  those  trades  connected  with  cutting,  quarry- 
ing, or  working  stone  of  all  sorts,  grinding  and  cutting  glass  and 
diamonds,  and  also  in  the  production  of  or  employment  in  plaster, 
cement,  pottery,  carborundum,  emery,  graphite,  carbide  of  calcium, 
and  many  other  mineral  products.  It  is  impossible  to  estimate  the 
relative  importance  of  the  parts  played  by  the  inhalation  of  dust  of 
sulphuretted  hydrogen  carbon  monoxid,  and  the  ingestion  of  dust 
with  the  use  of  alcoholic  beverages  in  the  production  of  disease  among 
miners  and  quarry  men.  Lindemann,^  basing  his  figures  on  a  trade 
organization  numbering  357,321,  shows  that  diseases  of  the  digestive 
organs  lead  the  list  in  the  order  of  frequency  with  11.1  per  cent,  per 
year,  while  diseases  of  the  respiratory  organs  come  second  with  fre- 
quency of  8.1  per  cent.  The  ingestion  of  irritating  dust  may  be  re- 
sponsible for  a  considerable  part  of  this  first  class,  while  heat  and 
humidity,  abrupt  changes  in  temperature  and  overwork  may  bear  part 
of  the  responsibility  for  the  second  class. 
^  As  pointed  out  by  Nieszytka,^  the  character  of  dust  doubtless  plays 
a  more  important  role  than  the  amount,  for  we  are  not  otherwise  able 
to  explain  the  comparative  innocuity  of  coal  dust.  Ogle^  shows  con- 
clusively that  the  coal  miners  a.re  the  least  affected  by  phthisis  and 
lung  diseases  of  any  class  engaged  in  dusty  occupations.     As  pointed 

^U.  S.  Department  of  Labor  Bulletin  79. 

^  Disease  and  Accidents  of  Miners  and  Tunnel  Workers  in  U.  S.  15th  Int. 
Cong,  on  Hygiene.,  Vol.  Ill,  Part  II,  Washington,  D.  C,  1913. 

^Nieszytka:  Viertaljahrscht.  f.  Gericht,  Medizin,  etc.,  1912,  Vol.  43,  Suppl. 
Heft.  1  and  2,  p.  143. 

*  Forty-fifth  Annual  Report  of  the  Registrar  General,  England. 


HEALTH  HAZARDS  IN  OCCUPATIONS  207 

out  by  Collis^  the  death  rate  from  tuberculosis  among  miners  is  onlj'^ 
high  under  exceptional  conditions.  In  rock  drilling,  particularly  siliceous 
rock,  the  danger  of  this  infection  is  especially  high,  as  it  is  also  among 
those  working  in  quartz  rock.  This  is  because  of  especially  harmful 
characteristics  of  the  sharp  and  pointed  edged  crystals  of  the  dust 
evolved  from  working  in  these  minerals.  The  harmful  characteristics 
of  the  dust  from  these  minerals  is  startlingly  shown  in  the  statistics 
of  the  mortality  in  the  region  around  Butte,  Montana,  and  the  Joplin 
District,  Missouri,  compiled  by  Lanza  and  Higgins.^ 

Most  conspicuous  among  the  industries  which  are  hazardous  be- 
cause of  the  production  of  vegetable  dust  are  those  dealing  with  the 
production  of  textiles  especially  the  ones  in  which  hemp,  flax  and 
jute  are  handled.^  In  the  carding,  ginning,  and  preparation  of  cot- 
ton for  cloth  manufacture,  an  especially  revolting  aspect  of  the  dust 
hazard  is  to  be  found  in  the  customary  employment  of  large  numbers 
of  women  and  children  which  prevails  under  the  most  distressing  con- 
ditions in  those  southern  states  in  which  factory  inspection  is  most 
lax  and  opposition  to  the  passage  of  proper  statutes  for  the  regulation 
of  the  minimum  age  of  employment  and  hours  of  labor  for  these 
is  most  stubborn.  Even  in  the  best  regulated  mills  the  work  of 
the  employee  involves  constant  confinement  in  a  dusty  atmosphere. 
In  the  weave  rooms  and  in  ring-spinning  rooms  there  is  no  method  of 
alleviating  the  dust  hazard  except  that  of  general  ventilation  ex- 
haust apparatus  not  being  feasible.*  In  the  card  stripping  process, 
recently  invented  machines,  now  in  use  in  many  mills  in  New  England 
and  to  some  extent  in  the  southern  states,  replace  hand  labor  thus 
reducing  number  exposed. 

The  general  processes  involved  in  the  manufacture  of  woolen  goods 
carry  the  same  health  hazards  as  those  of  the  cotton  industry;  sorting, 
carding,  combing,  spinning  and  weaving  being  the  most  dusty.  Occa- 
sional cases  of  anthrax  infection  result  from  this  industry.  Hoffman's^ 
statistics  based  on  155  deaths  among  carpet  and  rag  makers  show  23.9 
per  cent,  were  due  to  consumption  and  16.9  due  to  other  diseases  in 
the  respiratory  tract.  In  the  flax  and  linen  industries,  the  health 
hazard  due  to  dust  is  greater  than  in  the  woolen  mills.  The  ''heck- 
ling" process,  being  the  most  dusty,  results  in  so-called  "mill  fever," 
to  which  our  attention  is  called  by  Oliver.^ 

The  death  rate  from  tuberculosis  in  Belfast''  with  30,000  of  its 

^  Transactions  International  Congress  of  Medicine,  London,  1913. 

2  Technical  Paper  No.  105,  U.  S.  Bureau  of  Mines,  1915. 

^  Bulletin,  U.  S.  Dept.  of  Labor,  Bureau  of  Labor  Statistics  No.  127. 

*  Harrington- Richardson :  "Practical  Hygiene,"  p.  650. 

6  Bulletin  Bureau  of  Labor  No.  79,  1908. 

^Oliver:  "Diseases  of  Occupation,"  London,  1908. 

^  Ferris,  G.  H.:  Journal  of  State  Medicine,  March,  1895. 


208  INDUSTRIAL   MEDICINE    AND    SURGERY 

population  engaged  in  the  linen  industry  was  4.1  per  cent,  per  1000  as 
compared  with  1.4  per  cent,  for  the  whole  of  England  and  Wales  and 
2.1  per  cent,  for  Ireland.  In  the  manufacture  of  cordage,  twine,  jute 
including  gunny  cloth  of  which  jute  is  the  principal  material,  crash 
toweling,  linen  thread,  nets  and  skeins,  the  work  is  now  largely  done 
by  machinery  except  the  preliminary  opening  of  the  baled  mat^ial 
and  feeding  it  into  softening  machines  which  is  very  dusty. 

The  dangerous  dusts  arising  in  the  manufacture  of  dyes,  especially 
coal  tar  dyes  and  those  emanating  from  such  mordants  as  arsenite 
of  sodium  which  are  used  before  the  application  of  coal  tar,  and  those 
from  the  lead  salts  used  in  calico  printing  and  yarn  dyeing  are  becom- 
ing less  of  a  hazard  because  of  the  modern  regulations  covering  their 
use.  Clayton^  found  dust  arising  from  lead  and  the  chromic  acid  salts 
of  lead  still  prevalent  causes  for  poisoning  in  Great  Britain  in  1906. 

The  most  drastic  preventive  measures  against  poisoning  from  dust 
produced  in  dye  works,  should  be  in  effect  in  every  state.  The 
principal  safeguards  are  the  mechanical  suction  ventilation  by  fans  of 
all  parts  of  the  dye  processes  from  which  any  dust  arises;  the  changing 
of  clothing  at  the  completion  of  each  day's  work;  special  lockers  for 
street  clothing  to  prevent  dust  and  contamination;  compulsory  wash- 
ing of  the  hands  and  face  before  meals  and  facilities  for  eating  meals 
in  rooms  entirely  separated  from  the  industry;  and  the  use  of  respira- 
tors in  especially  dusty  places.  Impervious  oily  applications  to  the 
skin  are  also  indicated  in  some  parts  of  the  industry. 

Careful  study  of  the  ill  effects  of  the  dust  arising  in  the  boot  and 
shoe  industry  has  been  made  by  J.  Beatty,^  Medical  Officer  of  Health 
of  Northampton,  England,  where  he  found  the  death  rate  from 
tuberculosis  among  operatives  in  this  industry  to  be  2.59  per 
1000  as  compared  with  the  normal  average  of  2.08  per  cent,  for  the 
whole  population.  F.  L.  Hoffman^  in  the  study  of  the  causes  of 
death  in  the  city  of  Brockton,  Mass.,  found  25  per  cent,  of  the  deaths 
among  shoemakers  to  be  due  to  pulmonary  tuberculosis  and  11.4  per 
cent,  to  other  lung  diseases.  Among  the  various  processes  in  this 
industry,  heel  polishing  and  bottom  sanding  probably  have  the  greatest 
dust  hazard. 

The  high  percentage  of  pulmonary  tuberculosis  among  tailors  and 
garment  workers  as  instanced  strikingly  in  many  investigations  and 
typically  in  that  of  Epstein,^  who  found  43.7  per  cent,  of  the  deaths 
among  tailors  to  be  caused  by  pulmonary  tuberculosis,  is  of  course  by 
no  means  entirely   due  to   exposure  to   dust.     Overworking,   over- 

1  Clayton:  Brit.  Med.  Journ.,  1906,  Vol.  I,  p.  310. 

2  Ibid. 

3  Hoffman,  F.  L.:  Bulletin  Bureau  of  Labor,  No.  82,  May,  1909. 

*  Epstein:  "Weyl's  Handbuch  d.  Arbeiterkrankh.,"  Jena,  1908,  p.  310. 


HEALTH  HAZARDS  IN  OCCUPATIONS  209 

crowding,  underfeeding  and  poor  ventilation,  as  well  as  filthy  home 
conditions,  are  all  factors  of  importance  in  its  production. 

Occupations  concerned  with  the  sorting  of  linen,  wollen  and  cotton 
rags,  and  the  operation  of  machines  for  shredding  rags  in  the  produc- 
tion of  shoddy  are  very  dusty  ones.  These  processes  are  being  more  and 
more  handled  by  machinery.  Many  infectious  diseases  from  contami- 
nated cloth  can  be  spread  in  such  occupations,  among  which  small 
pox,  anthrax,  scarlet  fever,  tuberculosis  and  diphtheria  have  nrost 
often  been  recognized  as  resulting  from  "occupational  exposure." 
Disinfection  of  the  rags  before  shredding  would  prevent  these,  but 
chronic  affections  of  the  air  passages  from  the  constant  inhalation  of 
this  organic  dust  can  only  be  eliminated  by  proper  ventilation.  When 
rags  are  made  into  wall  paper,  danger  from  inhalation  of  bleaching 
chemicals  enters  as  another  hazardous  factor.  Furthermore,  in  the 
production  of  wall  paper,  many  of  the  dyes  contain  arsenic  or  lead 
pigments  which  give  rise  to  poisonous  dust.  Men  employed  in  wall 
paper  works  should  be  examined  at  definite  periods  the  same  as  any 
other  men  engaged  in  handling  poisonous  chemicals. 

The  amount  and  character  of  the  dust  evolved  in  wood  working 
industries  depends  upon  the  character  of  the  wood  used.  Dust  particles 
from  hard  wood  are  finer,  sharper  and  more  irritating  to  the  respira- 
tory passages  than  from  soft  wood.  Among  those  which  produce  a 
toxic  or  especially  irritating  dust  are  (1)  "sequoia  wood, "^  (2)  "coco- 
bola  wood,  "^  and  (3)  "sabion  wood,  "^  which  produces  catarrhal  symp- 
toms, the  Japanese  hard  wood  "Togayasa, "  satin  wood,  blue  gum, 
Indian  rosewood,  African  boxwood,  teak,  and  many  more  exotic  hard 
colored  woods  of  oriental  origin. 

Sommerfield^  estimates  the  mortality  rate  among  wood  workers 
in  Prussia  as  6.6  per  1000,  while  Roth^  estimates  that  61.7  per  cent,  of 
all  deaths  among  wood  turners  in  Berlin  between  1890  and  1897  were 
fcaused  by  phthisis. 

Sphtting  and  sorting  rattan  in  chair  factories,  whip  and  walking 
stick  manufacture,  and  furniture  repair  work,  all  carry  a  high  health 
risk  on  account  of  the  dust  hazard  in  most  workshops. 

In  threshing  grain,  storing  and  sorting  it  in  elevators,  flour  milling, 
and  baking,  machinery  is  replacing  the  hand  work  and  "millers' 
asthma"  and  tuberculosis,  once  prevalent  in  some  of  these  trades, 
are  consequently  diminishing. 

Much  discussion  has  arisen  oyer  the  supposed  health  hazards 

^Oliver:  "Dangerous  Trades." 

2  Neisser:  Internat.  Ubersicht  iiber  Gewerbehygiene,  Berlin,  1907. 
^Nestler:  "Prometheus,"  Berlin,  1913. 
^  "  Handbuch  der  Gewerberkrankbeiten,"  Berlin,  1909. 
^"Gewerbehygiene,"  Leipzig,  1907. 
14 


210  INDUSTRIAL    MEDICINE    AND    SURGERY 

in  the  manufacture  of  cigars  and  cigarettes,  and  other  forms  of 
tobacco,  and  the  U.  S.  Census  Bureau  among  twenty-three  occupations 
tabulated,  places  the  rate  of  death  from  tuberculosis  in  this  industry 
second  only  to  that  for  marble  and  stone  workers.  Typical  amblyopia 
such  as  is  produced  by  nicotin  is  reported  quite  frequently  among 
tobacco  workers  who  do  not  use  tobacco  in  any  form.^  These  in- 
toxications may  be  due  quite  probably  to  ingestion  of  tobacco  or 
tobacco  juices  and  possibly  to  absorption  of  nicotin  through  the  skin  as 
well  as  to  the  inhalation  of  tobacco  dust. 

INDUSTRIAL  POISONS,  OCCUPATIONAL  INTOXICATIONS,  GASES  AND 

FUMES 

Intoxications,  poisonings  or  illnesses  resulting  directly  from  the  dele- 
terious action  of  materials  used  in  the  industries  upon  the  body  are 
variously  defined  for  legislative,  administrative  and  medicolegal  pur- 
poses. Rambousek,^  omitting  industrial  infections,  defines  substanti- 
ally an  industrial  poisoning  as  one  produced  or  somehow  occasioned  in 
industrial  occupation  and  which  is  brought  about  inadvertently  and  con- 
sequently against  the  will  of  the  person  poisoned.  Kober^  defines  dis- 
eases of  occupation  as  injuries  and  disturbances  of  health  contracted  in 
industrial  pursuits,  and  other  vocations  in  life,  as  a  result  of  exposure  to 
toxic  agents,  infectious  organisms,  or  other  conditions  inimical  to 
health.  This  is  an  admirable  definition  since  it  includes  a  recogni- 
tion of  such  factors  as  fatigue,  epidemics  from  crowding,  speed  of  work, 
over-specialization,  prolonged  periods  of  labor,  faulty  ventilation, 
and  all  others  the  close  relation  of  which  with  the  more  specific 
causes  of  occupational  diseases  is  often  unrecognized.  Industrial 
poisons  are,  from  a  medicolegal  viewpoint,  well  defined  by  Dr. 
R.  Fischer  and  this  definition  is  approved  by  the  advisory  council  of 
hygiene  of  the  International  Association  of  Labor  Protection.  "  Indus- 
trial poisons  are,  in  general,"  he  says,  "those  raw  materials  and' 
products,  by-products,  and  waste  products  which  in  their  extrac- 
tion, manufacture,  and  use  in  industrial  processes  may,  notwith- 
standing the  exercise  of  ordinary  precaution,  find  entrance  into  the 
body  in  such  quantities  as  to  endanger,  by  their  chemical  action, 
the  health  of  workmen  employed."  Dr.  Fischer  has  also  revised  the 
list  of  industrial  poisons  elaborated  in  1908  by  Prof.  Thomas  Sommer- 
field.  Sir  Thomas  Oliver,  and  Prof.  Felix  Putzey.  This  has  been  im- 
proved and  edited  by  the  International  Association  of  Labor  Legislation 
and  furnishes  the  most  trustworthy  and  authoritative  list  available 

1  Galezowski:  "  Des  Ambly  op.  et  Amauroses  toxigues,"  1897.  DeSchweinitz : 
"The  Toxic  Amblyopias,  Etc.,"  1896. 

2  "  Industrial  Poisoning,"  p.  159. 

^  Kober  and  Hanson : "  Diseases  of  Occupation  and  Vocational  Hygiene,"  p.  417. 


HEALTH  HAZARDS  IN  OCCUPATIONS  211 

at  present.  A  translation  published  by  the  Bureau  of  Labor  in 
Bulletin  No.  100,  and  also  by  Kober  and  Hanson,  is  reproduced  at 
the  end  of  this  chapter.  The  diseases  here  listed  are  classified  with 
reference  to  their  chemical  causes,  and  fifty-four  poisons  are  dealt 
with. 

By  a  simple  method  of  classification,  now  classical,  suggested  by 
Rambousek,^  industrial  poisons  are  divided  into: 

1.  Poisons  which  act  superficially,  i.e.,  which  cause  in  the  organs 
they  touch,  gross  anatomical  lesions  (irritation,  corrosion,  etc.), 
the  so-called  contact  effect.  To  this  class  belong  irritant  and  corro- 
sive poisons. 

2.  Blood  poisons,  i.e.,  poisons  which  are  absorbed  by  the  blood 
and  change  it.  This  change  can  affect  either  the  blood  coloring 
matter  which  combines  with  certain  poisons  to  form  chemical 
compounds,  or  the  red  blood  corpuscles  themselves  can  be  altered  or 
destroyed  by  poisons  having  hemolytic  or  agglutinating  actions. 

3.  Poisons  with  definite  internal  action,  the  so-called  remote  or 
specific  effect.  To  this  class  belong  the  poisons  which,  after  being 
absorbed  into  the  system  act  upon  particular  organs  or  tissues  in  a 
specific   manner    (nerve   poisons,    heart   poisons,    etc.). 

It  is  indeed  possible  for  one  poison  to  display  two  or  even  all 
three  of  these  modes  of  action.  Industrial  poisons  can  be  absorbed 
(1)  as  solid  substances;  (2)  as  liquids;  and  (3)  as  gases.  Of  the  effects 
and  dangers  the  absorption  of  poisonous  substances  in  the  form  of 
dust  we  have  already  spoken.  Industrial  poisons  which  contaminate 
the  air  of  the  factory  in  the  form  of  gases  or  dust  are  inhaled,  or 
swallowed  and  absorbed  through  the  alimentary  system,  or  both.  As 
a  rule  only  liquid  poisons  enter  the  body  through  the  skin. 

Often  repeated  or  continuous  absorption  of  small  quantities  of  poi- 
son produces  slowly  developing  symptoms,  but,  as  in  lead  poison,  acute 
symptoms  may  develop  after  long  exposure  to  the  deleterious  effects 
of  small  quantities  of  the  toxic  material.  Acute  industrial  poison 
sometimes  develops  so  suddenly  that  unconsciousness  may  super- 
vene before  the  affected  workman  can  withdraw  himself  from  the 
influence  of  the  poisonous  agent  as  may  be  the  case  in  carbon  mon- 
oxid  or  mineral  acid  fumes  poisoning.  The  effects  of  various  poisons 
vary  in  severity  and  acuity  from  fatal  attacks  of  acute  chlorin  or  ben- 
zine poisoning,  to  the  chronic  intoxications  from  lead,  mercury,  arsenic, 
phosphorus,  etc. 

It  must  be  remembered  that  an  important  role  in  the  production 

of  an  occupational  poisoning  in  any   particular   case   is   played   by 

the  factors  of  dosage  per  unit  of  body  weight,  rapidity  of  absorption, 

and  such  predisposing  causes  as  individual  susceptibility,  acclimatiza- 

^ "  Industrial  Poisoning,"  p.  158. 


212  INDUSTRIAL   MEDICINE    AND    SURGERY 

tion  or  tolerance  to  the  particular  poison,  low  state  of  vitality,  pre- 
vious illness,  bronchial  or  gastric  affections,  wounds  and  abrasions 
of  the  skin  and  alcoholism  as  well  as  the  functional  state  of  the  organs 
through  which  toxic  substances  are  eliminated  from  the  body,  i.e.,  the 
intestines,  lungs,  liver,  kidneys,  and  skin.  The  possibility  of  intoxi- 
cation by  any  particular  poison  presupposes  its  solubility  by  the  "body 
juices." 

Laws  requring  the  reporting  of  cases  of  occupational  diseases  and 
industrial  poisoning  in  the  industries  have  been  so  recently  enacted,  and 
in  so  few  states,  the  detection  of  such  cases  in  factories  is  so 
infrequent  where  an  especially  trained  physician  is  not  employed 
for  the  purpose,  and  periodical  physical  examinations  of  workmen 
exposed  to  these  hazards  so  rarely  established,  that  in  America  it  is 
impossible  even  to  guess  at  the  extent  of  these  diseases.  In  1910  the 
First  National  Conference  on  Industrial  Diseases^  roughly  estimated 
that  there  were  at  least  13,400,000  cases  of  occupational  diseases  in 
this  country.  These  figures  were  based  on  the  number  of  cases  reported 
in  industries  in  continental  Europe  as  compared  with  the  number  of 
men  employed  in  similar  industries  here,  but  without  the  possibility 
of  allowance  for  a  comparison  of  the  preventive  measures  employed 
in  Europe  and  America. 

Aside  from  such  rough  estimates  there  have  been,  however,  occa- 
sional careful  pieces  of  work  done  upon  the  number  of  cases  of  certain 
occupational  diseases  in  this  country  in  very  limited  fields,  as  for  in- 
stance, the  study  by  Dr.  Andrews^  in  1910  of  the  phosphorous 
poisoning  occurring  in  fifteen  match  factories  in  which  65  per  cent,  of 
the  employees  were  exposed  to  the  dangers  of  such  poisoning  with 
eighty-two  cases  of  serious  poisoning  found  in  three  factories  alone; 
and  the  work  of  Drs.  Alice  Hamilton  and  Andrews  on  the  prevalence  of 
lead  poisoning  in  certain  trades,  done  under  the  authority  of  the  United 
States  Department  of  Labor  and  the  Illinois  Commission  on  Occupa- 
tional Diseases;  and  following  this  the  investigation  of  occupational 
disease  in  the  various  industries  by  various  workers  found  in  the  Bul- 
letins of  the  U.  S.  Department  of  Labor,  Bureau  of  Labor  Statistics, 
Nos.  95,  104,  120,  141,  165,  166. 

In  the  scope  of  this  chapter  a  comprehensive  description  of  all 
the  substances  which  may  be  injurious  to  the  health  of  working  people, 
the  industrial  processes  in  which  the  use  of  these  substances  is 
involved,  and  the  symptoms  each  produces,  is  impossible.  A  study 
of  the  references  given,  however,  will  enable  every  physician  in  in- 

1  "Memorial  on  Occupational  Diseases  of  the  First  National  Council  on  Indus- 
trial Disease." 

2  Phosphorous  Poisoning  in  the  Match  Industry,  Bulletin  186,  Uaited  States 
Bureau  of  Labor. 


HEALTH  HAZARDS  IN  OCCUPATIONS  213 

dustrial  medicine  to  completely  familiarize  himself  with  this  impor- 
tant subject. 

Before  a  consideration  of  measures  of  prevention,  a  brief  descrip- 
tion of  the  more  commonly  found  types  of  industrial  poisoning  and 
the  industrial  processes  in  which  they  frequently  occur  is  in  point. 

Lead  Poisoning 

Lead  poisoning  is  the  most  generally  recognized  and  most  widely 
spread  of  metallic  industrial  poisonings.  The  population  at  large  is 
also  frequently  affected  by  ingestion  of  this  metal  from  drinking  water 
and  beer  pipes,  bottled  beverages  where  lead  stoppers  are  used,  canned 
goods,  cosmetics,  lead  enameled  cooking  utensils,  and  a  myriad  other 
sources  more  difficult  of  detection.  It  is  typically  a  cumulative 
poison,  the  symptoms  appearing  either  as  those  of  an  acute  or  chronic 
intoxication.  Some  of  the  first  suspicious  symptoms  of  significance  to 
the  physician  engaged  in  industrial  medicine  are  pallor,  lassitude,  weak- 
ness or  loss  of  weight,  anorexia,  constipation,  or  alternating  constipa- 
tion and  diarrhea,  arteriosclerosis,  or  high  blood-pressure,  tremor  of 
the  tongue  or  hands,  wasting  of  the  subcutaneous  fat  especially  in 
the  infra-orbital  regions.  Any  of  these  may  be  the  initial  symptoms, 
and  developing  in  a  man  who  on  careful  physical  examination  reveals 
no  other  cause  for  it,  and  who  is  working  at  an  occupation  where  he 
is  exposed  to  the  chance  of  lead  poisoning,  should  be  considered  as 
gravely  suspicious  until  the  possibility  of  plumbism  is  entirely  and  def- 
initely eliminated.  The  classical  blue  line  on  the  gums,  which  is 
probably  due  to  the  formation  and  deposit  of  sulphide  of  lead  through 
the  action  of  sulphuretted  hydrogen  arising  from  decomposition  in  the 
mouth  cavity,  is  unfortunately  not  so  often  seen,  even  in  well  devel- 
oped cases,  as  was  formerly  believed,  some  recent  investigations  re- 
sulting in  the  identification  of  an  unquestionable  blue  Hne  in  no  more 
than  15  per  cent,  of  several  hundred  lead  pois6ning  cases.  Its  presence 
without  other  evidence  is  not  positive  proof  that  the  person  is  under 
the  influence  of  lead.  Indefinite  complaints  of  abdominal  pain,  not 
typical  lead  cramps,  in  a  man  exposed  to  plumbism  are  also  sufficiently 
suggestive  to  justify  the  physician  in  placing  the  worker  under  obser- 
vation and  instituting  repeated  examinations.  Arthritic  pains,  per- 
sistent headache,  occasional  slight  fever,  defective  vision,  neuritis, 
not  otherwise  explainable  on  physical  examination,  come  in  the  same 
category. 

With  the  development  of  compulsory  routine  medical  examina- 
tion or  inspection  of  workers  exposed  to  occupational  disease  hazards, 
and  requirement  by  the  state  of  the  reporting  of  all  cases  found,  the 
physician  in  industry  is  fortunately  being  held  to  stricter  and  stricter 


214  INDUSTRIAL   MEDICINE    AND    SURGERY 

accountability  for  the  early  diagnosis  of  lead  poisoning.  The  routine 
periodical  examination  of  such  workers  should  be  as  thorough  as  pos- 
sible. This  must  often,  unfortunately,  be  made  at  the  working  place 
of  the  employee  instead  of  in  a  physician's  office  or  plant  hospital. 
The  following  procedures  are  essential  to  such  an  examination  if  the 
earliest  cases  are  to  be  detected: 

1.  Inquiry  into  the  general  health  of  the  employee,  especially  in 
reference  to  headache,  anorexia,  joint,  muscular,  nerve  or  abdominal 
pains,  symptoms  referable  to  the  special  senses  and  history  of  the 
occurrence  of  constipation  or  diarrhea. 

2.  Examination  of  blood  pressure,  systolic  and  diastolic,  and  com- 
parison with  the  reading  at  previous  examinations,  and  palpation 
of  accessible  arteries  for  sclerosis. 

3.  Examination  of  the  urine. 

4.  Examination  of  the  gums  for  lead  line  and  of  mouth  with  a  view 
to  suggestions  for  the  correction  of  dental  conditions. 

5.  Observation  of  hands  and  tongue  for  tremors. 

6.  Examination  of  the  grip  and  wrist  extension  of  each  hand  by 
means  of  a  manometer,  both  the  grip  and  power  of  extension  being 
taken.  For  the  latter  the  manometer  can  be  fitted  into  a  portable 
wooden  frame.  The  readings  should  be  compared  with  those  at  previ- 
ous nonths  to  detect  the  beginning  of  muscle  weakness. 

Any  worker  in  whom  any  suspicious  findings  appear  during  such 
examination  should  be  called  to  the  physician's  office  or  plant  hos- 
pital for  complete  physical  examination  and  here  a  complete  history 
can  also  be  taken,  a  procedure  not  feasible  at  his  place  of  employment 
especially  since  a  history  of  impotence,  fetal  death  or  abortion  due 
to  plumbism,  and  difficult  to  elicit,  are  of  diagnostic  importance  in 
lead  poisoning.  The  offspring  may  even  be  affected  while  the  mother 
is  normal  and  the  father  "  leaded. "'• 

By  the  most  rigid  medicolegal  test  a  positive  diagnosis  of  plumbism 
entails  the  fulfillment  of  Gowers's  three  postulates  that: 

1,  Lead  must  be  demonstrated  as  entering  the  body  (this  by  a  study 
of  the  chances  of  ingestion  or  inhalation  of  dust  or  fumes  at  the  em- 
ployee's work). 

2.  It  must  be  demonstrated  to  be  in  the  body  by  indisputable  clin- 
ical symptoms  such  as  for  instance  typical  paralysis  or  lead  cramps, 
or  the  typical  changes  in  the  red  cells  consisting  of  the  diminution  in 
the  amount  of  hemogoblin   accompained   by   structural   changes  in 

1  Paul  cited  in  G.  C.  Nijhoffs  article  on  Action  on  Ovum  of  Superfluous 
Semen.  Nederl.  Tijdschr  v.  Geneeskunde,  Amsterdam,  ii,  No.  16.  Cole  and 
Bauckhuber:  Proc.  Soc.  Exper.  Biol,  and  Med.,  1914.  Weller  C.  V.:  Jour.  Med. 
Research,  1915,  xxxiii,  271.  Effect  on  Offspring  of  Lead  Poisoning  in  the  Father. 
Jour.  A.  M.  A.,  December  25,  1915,  Ixv,  No.  26. 


HEALTH  HAZARDS  IN  OCCUPATIONS  215 

these  cells,  as  evidenced  by  the  production  of  the  well  known  baso- 
philic granules  therein.  Other  changes  in  the  red  cells  less  commonly 
recognized  are  decreased  elasticity  and  reduction  of  the  powers  of 
resistance  to  chemically  acting  hemolytic  agents.  It  must  not  be 
supposed  that  any  of  these  changes  are  considered  as  pathognomonic 
or  characteristic  only  of  lead  poisoning  as  these  or  almost  identical 
changes  have  been  demonstrated  also  in  intoxications  by  phenyl 
hydrazine,  dinitro-benzene,  corrosive  sublimate,  and  other  poisons 
are  well  known  to  occur  in  such  wasting  diseases  as  pernicious  anemia, 
carcinoma,  leucemia,  grave  secondary  anemia  and  tuberculosis.  (In 
the  author's  experience  the  same  blood  findings  have  been  noted  in 
chronic  cerebrospinal  syphilis.) 

3.  The  final  postulate  to  be  fulfilled  is  the  demonstration  of  the 
excretion  of  lead  from  the  body.  Although  development  of  lead  neph- 
ritis, which  is  pathologically  not  distinguishable  from  other  chronic 
Bright's  disease,  may  occur  as  a  late  feature  of  plumbism,  and  suggests 
that  an  excretion  of  lead  through  the  kidney  often  takes  place,  re- 
peated examination  of  the  urine  even  in  well  developed  cases  of  plumb- 
ism generally  fails  to  reveal  the  presence  of  lead.  For  clinical  pur- 
poses it  is  generally  granted  that  lead  cannot  be  found  in  urine  where 
no  albumin  appears.  The  demonstration  of  lead  in  urine  should 
under  most  circumstances  be  left  to  the  chemist  as  its  positive  identi- 
fication involves  fairly  complicated  chemical  manipulation.  The 
presence  of  a  black  precipitate  in  the  urine  through  which  the  easily 
generated  hydrogen  sulphide  gas  has  been  passed  during  the  examination 
by  the  physician,  however,  is  sufficiently  suggestive  to  indicate  the  ad- 
visability of  a  thorough  chemical  examination  for  lead.  Elimina- 
tion of  lead  principally  as  the  sulphide  from  the  feces  does  not  of  itself 
prove  that  the  patient  is  ''  eaded, "  but  shows,  however,  that  he  is 
ingesting  the  metal  which  may  produce  plumbism  at  any  time  and 
makes  the  correction  of  the  faulty  factory  hygiene  or  personal  habits 
of  the  patient,  which  permitted  such  ingestion,  urgently  desirable. 
Diagnostic  tests  for  elimination  by  the  skin  are  scarcely  to  be  credited 
since  such  lead  excreted  by  the  skin  cannot  be  differentiated  from 
that  in  dust  settling  on  the  skin  in  the  workshops. 

However,  wherever  a  worker  even  remotely  exposed  to  plumbism 
presents  any  of  the  early  symptoms  suggestive  of  lead  poisoning,  he 
should  be  put  under  observation  by  the  physician  at  the  plant  and 
subjected  to  repeated  examinations  and  treatment  applied  until  his 
symptoms  have  disappeared  and  the  possibility  of  the  development 
of  plumbism  eliminated. 

The  typical  lead  colic  may  be  the  first  symptom  of  the  disorder 
and  some  investigators,  like  Sir  Thomas  Oliver,  believe  that  a  worker 
is  more  likely  to  develop  such  cramps  after  a  brief  exposure  than  are 


216  INDUSTRIAL   MEDICINE    AND    SURGERY 

men  exposed  to  the  danger  of  being  "leaded"  over  a  period  of  many 
years  and  who  often  develop  a  tolerance  to  its  action  on  the  gastro- 
intestinal system.  The  typical  colicky  pains  often  set  in  with  marked 
vehemence.  They  radiate  from  the  vicinity  of  the  umbilicus  in  all 
directions,  the  musculature  of  the  entire  abdominal  wall  becoming 
tense.  Pressure  on  the  abdomen  generally  relieves  the  pain  some- 
what. During  the  attacks  the  pulse  may  become  quite  slow.  Cathar- 
sis generally  fails  to  relieve  such  an  attack.  While  these  cramps 
frequently  last  from  a  few  minutes  to  a  half  hour  some  are  more  stub- 
born, continuing  with  remissions  for  days.  The  attacks  vary  greatly 
as  to  frequency,  following  one  another  in  a  series  or  occurring  singly 
weeks  or  even,  in  rare  cases,  years  apart. 

In  untreated  lead  poisoning,  motor  nerve  paralysis  is  very  apt  to 
develop  although  after  the  appearance  of  early  symptoms  some  workers 
seem  to  develop  a  certain  degree  of  tolerance  to  the  action  of  the  metal. 
The  commonest  type  of  lead  paralysis  is  that  first  affecting  the  ex- 
tensors of  the  wrists  and  later  all  the  muscles  supplied  by  the  radial 
and  ulnar  nerves.  Both  hands  are  generally  affected  and  the  progress 
of  the  affection  is  typical,  beginning  with  paralysis  of  the  ex- 
tensor digitorum  communis,  passing  to  the  remaining  extensors,  then 
to  the  abductor  muscles  of  the  hand.  Foot-drop,  affections  of  the 
facial  nerve  and  other  paralyses  are  less  common. 

The  early  recognition  of  lead  poisoning  is  essential  to  the  pro- 
tection of  the  worker  and  in  properly  conducted  shops,  with  careful 
medical  supervision,  suspicious  cases  should  be  recognized  as  such, 
treated  and  removed  from  the  injurious  action  of  lead  before  the 
development  of  extreme  anemia,  basophilic  degeneration  of  the  red 
corpuscles,  lead  paralysis,  or  encephalopathy. 

It  is  the  concensus  of  opinion  at  present  that  all  lead  compounds 
must  be  regarded  as  more  or  less  poisonous  although  formerly  a  large 
number  of  investigators  contended  that  only  those  salts  and  com- 
pounds soluble  in  water  or  weak  acids,  or  "the  juices  of  the  body" 
could  be  regarded  as  dangerous,  holding  that  all  others  were  incapable 
of  being  absorbed  into  the  body  and  hence  innocuous.  The  most 
readily  soluble  preparations,  the  acetate,  chlorid,  carbonate  (white 
lead),  oxid  of  lead  (lead  dross),  and  minium  (red  oxid)  are  most 
poisonous,  the  sulphate  and  iodid  is  less  poisonous,  and  the  insoluble 
sulphide  probably  is  the  least  poisonous  of  all.^ 

Among  the  dangerous  lead  trades  a  few  are  conspicuous  although 
poisoning  has  been  demonstrated  to  occur  in  so  many  it  is  difficult 
even  to  enumerate  them  all.  Oliver  in  his  "Dangerous  Trades"  states 
that  it  is  used  in  not  less  than  138  industries.  Thompson  mentions 
eighty-six.  As  an  isolated  instance  of  the  prevalence  of  lead  poison- 
1  Thompson:  "The  Occupational  Diseases,"  p.  204. 


HEALTH  HAZARDS  IN  OCCUPATIONS  217 

ing  in  American  industries,  Dr.  Hamilton  found  plumbism  in  thirty- 
three  out  of  fifty-six  factories  inspected  in  the  state  of  Illinois.  As  an 
illustration  of  the  wide  distribution  of  this  industrial  intoxication  she 
has  found  it  existing  in  the  industries  involved  in  the  manufacture 
of  white  lead,  litharge,  orange  mineral,  red  lead,  glazing  and  decorating 
white  wear  and  sanitary  earthenware  pottery,  tiles,  porcelain,  in 
smelting  works  and  lead  mining,  in  the  production  of  storage  batteries 
and  accumulators,  in  painting  processes,  rubber  goods  production, 
as  well  as  many  processes  never  thought  of  by  most  practicing  phy- 
sicians as  involving  such  a  hazard,  e.g.,  in  the  making  of  car  seals, 
tin  foil,  wrapping  cigars  in  tin  foil,  laying  electrical  cables,  making 
artificial  flowers,  china  painting,  handling  wall  paper  and  many  others. 

A  large  number  of  lead  poisoning  cases  have  been  reported  in  white 
lead  works.  In  America  there  are  four  processes  in  use  for  its  manu- 
facture: the  Old  Dutch,  the  Carter,  the  Matheson  and  the  Mild. 
In  the  first,  which  is  the  most  common,  the  lead  in  thin  discs  is  packed 
into  pots  of  acetic  acid  and  burned  for  about  one  hundred  days.  In 
stripping  out  the  white  lead  thus  produced,  a  great  deal  of  dust  is 
evolved  and,  in  the  type  of  this  process  used  in  the  United  States,  the 
work  cannot  be  made  less  hazardous  by  sprinkling  or  sluicing  the  lead 
with  water  as  is  done  in  England  and  Continental  Europe.  Unless 
suction  exhaust  ventilators  are  used  in  the  dry  pan  room,  a  great 
amount  of  lead  dust  is  inhaled  by  the  workers  here  also. 

In  the  Carter  process,  the  men  are  handling  finely  powdered 
material  and  the  hazard  is  great.  The  Matheson  and  Mild,  rarely 
used  in  America,  are  wet  processes  where  the  hazard  is  great  only 
while  packing  and  grinding  the  finished  product. 

The  roasting  of  lead  oxids  at  the  lead  smelters  or  in  connection 
with  making  of  white  lead,  produces  lead  fumes  from  the  furnaces 
and  dust  from  dumping,  grinding,  screening  and  packing  of  the  oxids. 

The  sources  of  lead  poisoning  in  the  pottery  trades  are  from  the 
ingredients  of  which  the  glazes  are  partly  composed,  the  least  danger- 
ous glazes  being  those  in  which  the  lead  is  added  at  the  beginning 
of  their  production  and  fused  with  the  other  ingredients  into  an 
insoluble  disilicate,  instead  of  adding  it  in  a  soluble  and  therefore 
poisonous  form,  later  in  the  process. 

The  painting  and  allied  trades  are  the  most  widespread  and 
important  lead  industries.  Among  the  most  dangerous  branches  of 
these  industries  are  interior  house  painting,  ship  and  carriage  painting, 
because  these  involve  dry  sandpapering  of  white  lead  paint,  which  is 
the  greatest  source  of  lead  dust  in  the  painting  trade.  In  ship  paint- 
ing red  lead  is  used  and  is  generally  dry  sandpapered,  or  chipped  off 
before  a  new  coat  is  applied. 

In  compounding  rubber  the  litharge  and  the  basic  sulphate  of  lead 


218  INDUSTRIAL    MEDICINE    AND    SURGERY 

are  ground  with  crude  rubber  by  warm  cylinders  and  much  dust  is 
evolved.  In  wall  paper  mills  and  lithograph  color  shops  minerals, 
some  of  which  contain  lead  salts,  are  ground  together  in  the  dry  state. 
Sommerfield  believes  that  plumbism  in  the  printers  trade  rarely 
appears  as  the  acute  form,  but  develops  insiduously  with  few  early 
diagnostic  symptoms,  being  manifested  only  by  general  reduction  in 
health  and  by  disturbances  of  digestion.  The  factory  physician 
examining  printers  periodically  for  occupational  diseases  must,  there- 
fore, go  over  each  case  history  thoroughly  and  make  careful  physical 
and  blood  examinations  if  he  expects  to  diagnose  the  cases  of  plumbism 
in  this  trade.  In  corroboration  of  this  opinion  it  is  an  interesting 
observation  that  in  an  intensive  study  of  one  hundred  printers,  taken 
at  random  from  the  trade  in  Chicago,  in  order  to  find  the  percentage 
presenting  symptoms  of  occupational  diseases,  I  found  four  with 
a  history  of  occasional  severe  pains  in  the  region  of  the  cecum,  but 
otherwise  in  fair  health,  who  had  been  operated  upon  for  supposed 
appendicitis  and  without  any  relief  of  symptoms  subsequent  to  the 
operation.  These,  I  believe,  were  quite  probably  mild  cases  of  lead 
intoxication  mistaken  by  the  surgeon  for  chronic  appendicitis.  In 
the  printing  trade  there  has  been  a  gradual  replacement  of  the  hand 
compositor  who  handles  lead  type  and  is  exposed  to  dust  arising 
from  the  type  cases,  by  the  type  setting  machine  operator  who, 
unless  the  machine  is  well  hooded  is  exposed  to  the  fumes  arising 
from  the  molten  metal.  With  this  change  in  the  method  of  handhng 
type  there  is  no  reason  to  believe  that  lead  intoxication  has  diminished 
in  frequency.  Beyer^  believes  that  machine  type  setting  increases 
it.  Fumes  from  unhooded  metal  pots  in  the  stereotyping  and  type 
casting  rooms  and  the  dust  from  the  floor  which  has  been  found  to 
contain  as  much  as  14  per  cent,  lead  are  both  dangerous  to  the  printers.^ 

Zinc  Poisoning 

The  chronic  gastric,  intestinal  and  nervous  diseases  found  by  the 
older  writers  occurring  in  zinc  smelters  which  they  regarded  as  due  to 
chronic  zinc  poisoning  are  now  accepted  as  certainly  due  to  the  lead 
always  present  in  zinc  and  it  is  generally  believed  that  there  is  no 
definite  clinical  condition  which  may  be  defined  as  chronic  zinc  or 
brass  poisoning. 

Zinc  ague,  known  also  as  brass  founders'  ague,  zinc  chills,  smelter 
shakes,  metal  shakes  and  brazier's  disease  is  a  form  of  acute  industrial 
zinc  poisoning.  This  ague  occurs  exclusively  in  brass  casters  and 
braziers   and  not  in  zinc  workers,      Sigel  and  Lehman^  have  shown, 

1  "Die  Volkswirthchaftliche  und  Sozial  politsche  Bedentung  der  Finfuhrung 
der  Setzmachine  im  Buchdruckgewerbe, "  p.  134. 
-  "  Oliver:  Diseases  of  Occupation,"  p.  180. 
3  Arch.  f.  Hyg.,  1910,  p.  358. 


HEALTH  HAZAKDS  IN  OCCUPATIONS  219 

however,  that  it  may  be  caused  by  burning  pure  zinc  and  inhaUng 
the  oxid  therefrom.  Lehman  beheves  that  the  zinc  oxid  produces 
''proteid  destruction"  in  the  respiratory  membranes  with  resorption 
of  the  destroyed  cells  into  the  system  and  that  these  dead  proteids 
acting  as  toxalbumins  produce  the  symptoms.  This  ague  consists  of 
an  acute  malaria  like  syndrome  of  a  chill,  sometimes  accompanied 
by  fever  lasting  one-half  to  three  hours,  terminating  in  profuse 
sweating  and  exhaustion.  This  chill  appears  an  hour  or  so  after 
inhaling  zinc  fumes  usually  in  the  form  of  brass  or  bronze  fumes  and 
generally  affects  those  unaccustomed  to  such  exposure.  A  temporary 
immunity  is  often  developed  after  the  attack. 

Arsenic  Poisoning 

Soluble  salts  of  arsenic  act  as  an  irritant  to  the  skin  causing  pig- 
mentation and  sometimes  the  so-called  "arsenic  pock,"  setting  up 
eczema  and  ulceration.  General  poisoning  may  be  caused  by  the  in- 
gestion of  salts  of  the  metal  or  inhalation  of  arsenical  fumes.  Acute 
poisoning  may  result  in  death,  while  the  effects  of  chronic  poisoning 
are  shown  first  upon  the  gastrointestinal  organs  and  later  upon  the 
heart  and  nervous  system.  The  first  acute  symptoms  are  anemia, 
nausea,  vomiting,  and  diarrhea  which  is  sometimes  accompanied  by 
severe  abdominal  cramps. 

In  the  chronic  cases,  nerve  affections  such  as  peripheral  neuritis 
with  paresthesia  and  anesthesia,  sometimes  accompanied  with  edema, 
are  more  frequent  than  complete  paralysis.  When  paralysis  occurs, 
however,  it  often  affects  mainly  the  lower  extremities  thus  differing 
from  plumbism. 

Excluding  the  cases  due  to  arseniuretted  hydrogen,  the  following 
table  from  the  Report  of  the  Chief  Inspector  of  Factories,  London, 
covering  the  years  1900-1913  inclusive,  gives  an  estimate  of  the  distri- 
bution of  arsenical  poison  in  various  English  trades  with  the  frequency 
of  occurrence. 

Industry  Total  cases 

Manufacture  of  emerald  green 46 

Extraction  of  arsenic 8 

Manufacture  of  sheep  dip 5 

Paint  and  color  works 4 

Chemical  works 3 

Smelting  of  metals  (lead  and  copper) 3 

Sorting  bird  skins 3 

Wall  paper  manufacture 2 

Shot  making 1 

Scraping  paint  off  ships 1 

Tanning 1 

Unloading  white  arsenic 1 

Indefinite 8 

Total 86 


220  INDUSTRIAL   MEDICINE    AND    SURGERY 

The  number  of  cases  reported  to  the  Chief  Inspector  of  Factories 
during  the  same  period  as  resulting  from  arseniuretted  hydrogen  gas 
was  thirty-three  and  these  were  found  chiefly  in  chemical  works  but 
also  in  the  galvanizing  trades,  bullion  refining,  bronzing  of  art  metal, 
paper  manufacture,  and  tin  plate  works.  Such  poisoning  often  ap- 
pears in  industries  where  the  working  force  and  superintendent  have 
no  thought  of  the  possibility  of  its  occurrence.  It  is,  however,  rare. 
The  symptoms  generally  set  in  a  few  hours  after  the  inhalation  of 
this  garlicky  smelling  gas.  Nausea  is  followed  by  repeated  vomiting. 
Intense  jaundice  of  the  skin  and  conjunctiva  then  appears,  and  grave 
hemolysis  occurs.^ 

Dr.  Rogers  reports  that  in  America  workers  in  the  following  in- 
dustries are  exposed  to  arsenical  poisoning:  making  of  artificial 
flowers,  manufacture  of  candles  and  wax  ornaments,  manufacture  of 
japanned  goods,  manufacture  of  carpets,  fancy  book  binding,  pre- 
servation of  wood,  manufacture  of  gloves,  and  of  sheep  dip,  electro- 
plating, lithographing,  and  bronzing,  manufacture  of  artificial  leather, 
oil  cloth,  linoleum,  cut  glass,  hat  linings,  beer,  soaking  of  silk  cocoons 
and  enameling.  He  adds,  "the  majority  of  the  workers  are  unaware 
of  the  poisonous  nature  of  the  material  handled  and  where  precautions 
are  taken  it  is  only  because  lead  compounds  are  also  used. " 

Mercury  Poisoning 

The  symptoms  of  mercurial  poisoning  depend  on  the  rate  of  absorp- 
tion of  the  metal.  It  is  possible  that  enough  mercurial  vapor  may 
be  inhaled  in  establishments  where  the  working  conditions  are 
extremely  bad  to  produce  severe  diarrhea  due  to  acute  mercuric 
chlorid  or  iodid  poisoning.  After  this  diarrhea  is  estabHshed  it  is 
accompanied  by  marked  tenesmus  and  may  become  bloody  in 
character.  It  is  generally  accompanied  by  vomiting.  Renal  symp- 
toms may  develop  and  anuria  supervene. 

Industrial  mercurialism  is  often  of  the  type  which  may  be  termed 
subacute  and  here  the  most  prominent  symptom  is  inflammation  of 
the  buccal  cavity.  There  is  at  first  only  an  increased  flow  of  saliva, 
foul  breath  and  disagreeable  metallic  taste  in  the  mouth.  Loosening 
of  the  gums  from  the  teeth,  pain  on  chewing  and  even  ulceration  of 
the  cheeks  and  lips  may  follow.  In  the  absence  of  a  history  of  expo- 
sure to  vapors  of  mercury  or  fumes  of  its  compounds,  this  stomatitis 
is  difficult  to  distinguish  from  that  due  to  other  causes,  for  instance, 
from  carious  teeth  in  which,  however,  the  gingivitis  is  primarily  lo- 
calized about  such  teeth. 

1  Second  Report  of  the  Factory  Investigating  Commission,  1913,  Vol,  ii,  p. 
1161. 


HEALTH  HAZARDS  IN  OCCUPATIONS  221 

In  mercurialism  more  slowly  acquired  and  of  a  more  chronic  form, 
while  stomatitis  may  be  present  and  intestinal  attacks  may  occasion- 
ally occur,  cachexia,  general  emaciation,  muscular  tremors,  decrease 
of  strength,  and  symptoms  of  nervous  and  mental  derangement,  such 
as  erethism,  are  more  conspicuous.  The  mercurial  tremor  when  well 
developed  is  somewhat  typical  and  consists  of  coarse  contractions  and 
jerks,  often  accompanied  by  a  finer  tremor. 

As  metallic  mercury  gives  off  vapors  even  at  ordinary  tempera- 
tures, poisoning  can  occur  in  its  recovery  from  the  ore  and  in  all 
processes  in  which  it  is  employed,  such  as  silvering  of  mirrors  (in  which 
the  nitrate  of  silver  and  ammonia  process  is  now  replacing  it),  making 
of  thermometers  and  barometers,  incandescent  electric  bulbs  in  which 
a  vacuum  is  produced  by  mercury  pumps,  e  ectrical  meters,  manufac- 
ture of  mercurial  salts  or  explosives,  derived  from  fulminate  of  mercury, 
rubber,  cosmetics  and  dyes,  bronzing,  and  in  ''carotting"  furs  with 
the  nitrate  and  making  felt  hats. 

Phosphorous  Poisoning 

The  symptoms  of  industrial  phosphorous  poisoning  are  of  the 
chronic  type  and  result  from  absorption  of  white  phosphorus  or  its 
fumes,  phosphuretted  hydrogen  or  fumes  arising  from  heated  phosphor 
bronze  and  ferrosilicon. 

"Phossy  jaw"  or  so-called  phosphorous  necrosis  is  a  striking  result 
of  industrial  phosphorous  poisoning  which  usually  starts  around  a 
carious  tooth.  It  begins  essentially  as  an  "ossifying  periostitis'* 
resulting  later  in  the  formation  of  abscesses,  sloughing  of  the  perios- 
teum and  necrosis  of  the  denuded  bone.  With  this  characteristic 
lesion  of  phosphorous  poisoning,  fragilitas  ossium,  anemia,  indigestion, 
cachexia  and  bronchial  catarrh  may  be  associated. 

Workers  generally  develop  phosphorous  poisoning  only  after  work- 
ing many  years  exposed  to  this  hazard. 

The  symptoms  of  the  rapidly  acting  phosphoretted  hydrogen 
poisoning  appear  immediately  after  it  is  inhaled;  dyspnea,  coughing, 
fainting  spells,  noises  in  the  head  and  nausea  develop  quickly,  and  in 
some  cases  coma  and  death  supervene. 

When  phosphorus  is  produced  from  bones  decomposed  by  sulphuric 
acid,  poisonous  fumes  are  evolved.  In  the  distillation  and  purifica- 
tion of  phosphorus,  dangerous  fumes  both  of  phosphorus  and  phos- 
phoretted hydrogen  arise.  One  of  the  triumphs  of  industrial  hygiene 
is  the  prohibition  of  the  production  at  the  present  day  of  phosphorous 
matches.  Ferrosilicon  is  used  in  the  manufacture  of  steel  and  phos- 
phor bronze  in  production  of  metals  for  use  in  manufacture  of  car- 
tridges and  cannons.     In  manipulating  both  of  these,  phosphoretted 


222  INDUSTRIAL    MEDICINE    AND    SURGERY 

hydrogen  gas  may  escape.     In  the  manufacture  of  acetylene  gas,  from 
calcium  carbide,  phosphoretted  hydrogen  is  produced  as  an  impurity. 

VOCATIONAL      HYGIENE      AND      PREVENTION      OF      OCCUPATIONAL 

DISEASES 

The  problem  of  eliminating  diseases  of  occupation  and  preventing 
the  enormous  waste  in  human  life  and  industrial  efficiency  due  to  their 
insidious  action  is  a  important  as  any  facing  the  industrial  world. 
This  problem  cannot  be  solved  without  the  co-operation  and  concerted 
action  of  all  concerned,  the  state,  the  employer,  the  employee,  and  the 
specially  trained  workers  at  their  disposal,  i.e.,  safety  engineers,  effi- 
ciency experts,  heads  of  departments  of  human  maintenance  in  indus- 
tries, factory  inspectors  and  investigators,  and  medical  men  trained 
in  the  science  of  the  early  detection  and  treatment  of  these  diseases. 

Just  as  experience  and  special  investigation  have  demonstrated 
that  industrial  accidents  represent  an  unnecessary  expense  in  the  con- 
duct of  manufacturing  enterprises  and  a  preventable  loss  of  working 
efficiency,  so  application  of  the  principles  of  prevention  of  occupational 
diseases  and  protection  of  workers  against  them  will,  in  the  opinion 
of  every  man  conversant  with  the  loss  of  labor  and  productive  effi- 
ciency due  directly  to  these,  gradually  show  on  the  books  of  the  indus- 
tries, in  actual  profits  and  in  savings  of  expense  of  operating,  the  sound 
business  judgment  of  applying  these  principles. 

The  conservation  of  the  health,  vitality,  and  industrial  usefulness 
of  wage  earners  is  of  concern  to  every  person  in  a  democratic  nation. 
The  protection  of  the  worker  and  the  prevention  of  occupational  dis- 
eases and  health  hazards  is  necessarily  a  function  of  any  government 
conducted  "for  the  people."  In  the  United  States  these  problems 
can  best  be  attacked  through  our  legislative  bodies,  (1)  by  investiga- 
tion either  by  special  committees  or  by  permanent  boards  and  com- 
missions, (2)  by  legislation,  and  (3)  by  administration  and  enforce- 
ment of  such  measures  through  special  officers,  and  factory  inspection 
departments,  (4)  by  education  of  employer,  employee,  and  the  public 
in  the  dangers  and  avoidance  of  health  hazards.  All  these  measures 
are  necessarily  expensive.  As  an  example,  in  the  state  of  New  York 
during  1912-13  the  legislature  appropriated  $110,000  to  the  factory 
investigating  commission,  which  did  not  include  the  usual  sustain- 
ing funds  for  the  permanent  departments  of  health  and  labor. 

Only  after  thorough  investigation  of  the  occupational  diseases  and 
health  hazards  specific  to  certain  industries  can  rules  for  the  preven- 
tion of  health  hazards  and  for  proper  industrial  hygiene  of  employees 
be  drafted.  All  provisions  in  England  for  factory  acts  relative  to  health 
hazards  have  followed  the  report  of  the  Departmental  Committee  on 
Dangerous  Trades  which  was  actively  engaged  in  investigation  for 


HEALTH  HAZARDS  IN  OCCUPATIONS  223 

several  years.  All  revisions  of  these  acts  are  now  based  on  the  findings 
of  special  investigations  ordered  by  Parliament.  The  present  statutes 
covering  the  reporting  and  prevention  of,  and  compensation  for  occu- 
pational diseases  in  Illinois,  New  York,  and  a  few  other  states,  are  the 
legislative  results  of  the  reports  of  Occupational  Disease  committees. 
About  the  year  1870  general  interest  in  the  discussion  of  a  pro- 
ject for  the  establishment  of  some  international  organization  for  the 
protection  of  workers  first  began  to  appear.  In  1873  the  socialist 
party  in  France  suggested  the  possibility  of  such  a  plan.  Von  Bis- 
mark  was  naturally  opposed  to  the  participation  of  Prussia  in  any 
type  of  international  convention.  During  the  next  few  years  trade 
unions  in  England,  France  and  Switzerland  continued  the  discussion 
of  the  project  and  in  March,  1890,  the  first  international  conference 
for  the  protection  of  workers  was  held.  It  has  met  regularly  since 
that  time  in  various  countries.  The  study  of  methods  of  codifying 
the  laws  governing  labor  conditions,  the  collection  and  publishing  of 
literature  bearing  on  the  protection  of  laborers,  and  the  prevention 
of  health  hazards  have  occupied  the  attention  of  this  body.  The 
prevention  of  the  use  of  white  phosphorus  in  making  matches  in  various 
countries  has  resulted  directly  from  suggestions  made  by  this  conference. 
International  agreements  for  the  protection  of  workers  are  highly 
advisable  on  economic  grounds,  since  if  every  nation  makes  its  own 
restrictions,  advantage  in  the  worlds  market  is  thereby  granted  to  the 
nation  whose  manufacturers  are  allowed  to  produce  articles  by  cheap, 
hazardous  methods  prohibited  in  other  nations.  Also,  it  is  reasonable 
and  just  on  humanitarian  grounds  that  workers  should  be  protected 
irrespective  of  race  or  nationality. 

FEDERAL  LEGISLATION  AND  ADMINISTRATION 

The  authority  of  our  federal  government  in  the  interest  of  public 
as  well  as  industrial  health  rests  in  the  clause  of  the  Constitution 
relating  to  the  power  of  Congress  over  the  operations  of  interstate 
and  international  commerce,  and  the  clause  relating  to  common 
welfare.  By  an  act  approved  August  14,  1912,  the  United  States 
Public  Health  Service  "was  authorized  to  study  and  investigate 
the  diseases  of  man  and  the  spread  thereof,"  and  to  publish  informa- 
tion to  the  public.  On  August  23,  1912,  Congress  authorized  the 
appointment  of  a  temporary  ''Commission  on  Industrial  Relations" 
among  whose  duties  is  that  of  inquiring  into  matters  relating  to  the 
health  of  employees.  On  April  9,  1912,  Congress  established  the 
Children's  Bureau  which  has  among  its  functions  the  investigation  of 
child  labor  in  the  industries.  As  a  result  of  the  recommendations 
of  the  International  Associations  and  the  investigations  of  the  occur- 


224  INDUSTRIAL   MEDICINE   AND    SURGERY 

rence  of  phosphorous  poisoning^  in  the  match  industry  in  this  country, 
by  agents  of  the  United  States  Bureau  of  Labor  in  1900  and  in  1909, 
and  the  American  Association  for  Labor  Legislation,  Congress  on  April 
9,  1912,  passed  an  act  abolishing  the  use  of  phosphorous  matches  by 
laying  a  prohibitive  tax  upon  them. 

With  the  entrance  of  our  country  into  the  world  war  and  the  sub- 
sequent increase  in  production  of  war  materials  under  government 
contract,  a  great  opportunity  has  been  given  to  the  federal  govern- 
ment to  supervise  and  control  all  health  hazards  in  those  industries 
under  such  government  contracts.  Protection  of  employees  is 
essential  to  speeding  up  of  production.  Therefore,  the  federal  govern- 
ment should  include  in  every  contract  provisions  for  the  protection 
of  employees  against  all  occupational  conditions  tending  to  destroy 
efficiency  by  disease  or  accident  hazards. 

The  functions  of  the  United  States  Department  of  Labor  are 
limited  to  the  work  of  ''investigation  and  study  and  diffusion  of  in- 
formation regarding  the  means  of  promoting  the  material,  social, 
intellectual,  and  moral  prosperity  of  the  working  men  and  women." 
It  is  quite  within  its  scope  therefore  to  study  factory  processes  and 
conditions  with  a  view  to  eliminating,  restricting  or  safeguarding 
the  use  of  poisonous  and  injurious  materials,  or  to  study  lighting, 
ventilation,  humidity,  the  disposal  of  dust  and  fumes,  and  the  im- 
provement of  the  hygienic  conditions  of  the  working  places.  In 
the  group  of  its  reports  relating  to  factory  inspection  and  occupa- 
tional hygiene,  are  included  articles  in  regard  to  the  inspection  of 
factories  and  workshops  in  this  and  in  foreign  countries.  Detailed 
suggestions  in  regard  to  factory  inspection  and  legislation,  and  the 
regulation  of  working  conditions,  especially  in  industries  and  occupa- 
tions involving  special  dangers,  have  been  made  the  subject  of  particular 
attention.  Special  studies  have  also  been  made  of  the  morbidity  and 
mortality  in  certain  dangerous  occupations  and  of  the  dangers  to 
employees  who,  in  the  course  of  their  work,  come  in  contact  with 
poisonous  materials.  Under  this  head  the  most  important  work  which 
has  been  done  is  the  study  of  phosphorous  poisoning  in  the  match 
industry,  of  lead  poisoning  in  the  lead  industries,  and  in  the  manu- 
facture of  pottery,  tiles,  and  porcelain  enameled  sanitary  ware,  and 
the  recent  studies  in  T.  N.  T.  and  other  munition  poisonings.  In 
all  these  industries  investigation  has  disclosed  the  existence  of  danger- 
ous conditions  most  of  which  may  be  entirely  eliminated,  or  very 
greatly  improved,  without  serious  difficulty.  All  of  these  investiga- 
tions have  strongly  emphasized  the  fact  that  by  a  study  of  working 
conditions  in  the  more  dangerous  and  unhealthful  occupations,  the 

^  Phosphorous  Poisoning  in  the  Match  Industry  by  John  B.  Andrews.  Bulletin 
86,  United  States  Department  of  Labor. 


HEALTH   HAZARDS    IN   OCCUPATIONS  225 

best  methods  of  prevention  may  be  made  available  for  use  in  those 
factories  where,  "because  of  ignorance  or  because  of  the  indifference 
resulting  from  ignorance,  dangerous  conditions  have  been  allowed  to 
continue  without  any  technical  necessity  and  without  any  economic 
need."i 

There  are  three  principal  legislative  methods  for  the  prevention  of 
occupational  disease: 

1.  By  prohibition. 

2.  By  regulation  including  inspection  of  employees  and  factories, 
licensing,  notification  of  cases,  and  by  special  rules  for  employ- 
ment in  special  industries,  hours  of  labor  and  rotation  or  variation 
of  employment. 

3.  By  compensation  and  insurance. 

The  method  of  prohibition  may  apply  to  (1)  processes  or  substance 
used,  or  (2)  certain  classes  of  people  who  are  restrained  from  partici- 
pating in  dangerous  trades.  Laws  have  been  enacted  in  many  foreign 
countries,  and  in  some  of  our  states,  by  which  children  under  a  specified 
age  or  even  all  minors,  and  also  women  of  certain  ages,  are  prohibited 
from  participating  in  any  work  which  is  considered  dangerous  or  from 
working  in  any  estabUshment  where  poisonous  dusts  or  injurious  gas  or 
fumes  are  evolved.  In  America  these  prohibitive  laws  for  women,  in 
most  states,  relate  only  to  employment  in  mines  and  saloons.  Women 
are  forbidden  to  work  in  mines  in  most  of  the  mining  states  and  in 
saloons  in  about  sixteen  states.  In  a  very  few  states  women  are  pro- 
hibited from  the  use  of  emery ,  polishing  or  buffing  wheels  where 
articles  of  iridium  or  of  the  baser  metals  are  being  manufactured.  In 
New  York  and  a  few  other  states  women  are  prohibited  from  night 
work.  In  Argentina,  England,  Germany,  France,  Italy  and  Holland 
women  are  prohibited  more  or  less  completely  from  work  involving 
the  use  of  lead.  In  America,  however,  although  their  peculiar  sus- 
ceptibiUty  has  long  been  known,  they  are  widely  employed  in  potteries, 
usually  in  dipping  the  ware  in  lead  glaze,  decorating  with  lead  colors, 
and  cleaning  or  sweeping  floors  or  tables  where  lead  dust  is  present. 
In  America,  as  is  shown  by  careful  investigation,  the  ratio  of  cases  of 
lead  poisoning  among  women  employed  in  potteries  is  one  in  seven, 
while  in  Great  Britain  the  ratio  is  one  in  sixty-four.  ^ 

In  the  case  of  lead  prohibitory  legislation  has  been  enacted  in 
several  European  countries  to  affect  certain  industries  and  processes. 
In  1908  Austria  forbade  the  use  of  lead  in  all  paints,   colors,   or 

^Verul,  Chas.  H. :  "The  Relation  of  the  U.  S.  Department  of  Labor  to  In- 
dustrial Hygiene."  Fifteenth  International  Congress  on  Hygiene  and  Demo- 
graphy, Vol.  i,  Pt.  ii,  p.  714. 

^Andrews,  I.  O. :  The  Protection  and  Promotion  of  the  Health  of  Women  Wage 
Earners  in  "Diseases  of  Occupation  and  Vocational  Hygiene,"  p.  134. 
15 


226 


INDUSTRIAL    MEDICINE    AND    SURGERY 


cements  used  for  interior  work,  while  the  Swiss  Government  prohibits 
its  use  in  the  form  of  white  lead  in  all  painting  done  under  the 
authority  of  its  executive  departments.  In  1909  France  enacted 
legislation  to  be  effective  in  July,  1914,  forbidding  use  of  white  lead, 
of  Unseed  oil  mixed  with  lead,  and  of  all  products  containing  white 
lead,  in  all  painting  of  any  nature,  either  on  the  outside  or  inside 
of  buildings. 

In  textile  mills,  tuberculosis  and  other  contagious  diseases  have 
been  spread  by  employees  sucking  thread  into  shuttles  and  accordingly 
in  1911,  Massachusetts  prohibited  the  use  of  any  form  of  shuttle  which 
in  threading  required  the  employee  to  use  his  lips  or  mouth. 


Fig. 


36. — Helmet  used  to  protect  eyes  and  face  of  arc-welders  from  ultra-violet  rays. 
(General  Electric  Co.) 


The  second  set  of  legislative  methods  for  the  prevention  of 
occupational  diseases  and  the  promotion  of  health  of  workers,  that 
of  regulation,  apply  to  a  large  group  of  occupations  and  processes 
where  injurious  materials  or  conditions  are  present  but  where  the  ill 
effects  on  the  employee's  health  are  less  definite.  This  group  includes 
all  those  occupations  where  the  workers  are  exposed  to  the  harmful 
action  of  extremes  of  temperature,   excessive  humidity,  insufficient, 


HEALTH  HAZARDS  IN  OCCUPATIONS  227 

poorly  regulated  or  distributed  light,  impure  air,  overcrowding, 
exposure  to  infectiou-s  diseases,  dust  and  fumes,  excessive  speed, 
extreme  strain  or  fatigue.  While  these  and  many  other- working  con- 
ditions produce  a  marked  effect  upon  the  health  of  working  people  and 
render  them  more  susceptible  to  such  diseases  as  rheumatism,  tuber- 
culosis, anemia,  pneumonia,  bronchitis  and  other  diseases  of  the  respira- 
tory tract,  functional  and  nervous  disorders,  eye  diseases  and  orthopedic 
derangements,  yet  it  is  often  difficult  to  designate  them  specifically  as 
due  to  occupational  causes  since  conditions  outside  the  work  may  play 
a  part  in  their  production.  There  are,  however,  many  diseases 
unquestionably  due  to  industrial  hygienic  conditions  or  poisons  which 
can  best  be  controlled  by  careful  governmental  regulation. 

The  control  of  working  conditions  in  the  industries  by  the  govern- 
ment is  accomplished  by  means  of  the  enactment  of  specific  laws 
or  statutes  or  through  the  agency  of  rules  or  orders  issued  by  adminis- 
trative authorities.  In  America  legislation  is  unfortunately  often 
couched  in  terms  too  general  or  ambiguous  and  so  easily  miscon- 
strued by  the  courts  and  almost  always  too  laxly  enforced.  Many 
times  the  bill  carries  no  definite  provision  for  sufficient,'  well  paid, 
competent    officers    to    enforce    its    regulations. 

Provisions  for  competent  inspection  of  dangerous  trades  must  in- 
clude not  only  the  requirement  of  frequent  visits  by  inspectors  to 
industrial  establishments  in  which  poisonous  gases,  fumes  and  faulty 
working  conditions  are  found,  but  also  the  delegation  to  such  inspectors 
of  the  power  to  enforce  observance  of  regulations. 

Compulsory  reporting  of  some  of  the  occupational  diseases  and 
cases  of  industrial  poisoning  is  being  included  in  practically  all 
statutes  covering  this  subject  which  are  being  passed  by  the  legislatures 
of  the  industrial  states.  Unless  the  data  supplied  by  such  reports 
is  carefully  tabulated  the  extent  of  protection  needed  and  the  results 
and  success  in  the  prevention  of  disease  by  such  measures  as  are 
being  applied  cannot  even  be  estimated.  Such  reporting  of  cases 
must  necessarily  devolve  upon  physicians  since,  because  of  their 
training,  they  are  the  only  class  capable  of  recognizing  maladies  due 
to  occupational  causes.  Among  physicians  men  especially  trained 
in  occupational  disease  detection  are  infinitely  more  valuable  for  such 
work  than  the  average  general  practitioner  because  many  of  the 
symptoms  of  occupational  diseases  have  but  recently  been  recognized 
and  the  existence  of  these  diseases  in  many  trade  processes  is  only 
now  being  discovered  by  men  specially  interested  in  the  subject. 
It  is  a  new  field.  The  teaching  of  the  intimate  relation  of  occupation 
to  disease  is  not  emphasized  in  the  average  medical  school  curriculum. 
In  Illinois,  Missouri,  New  Jersey,  Ohio  and  Pennsylvania  the  laws 
require   all   employees   engaged   in    certain   occupations   carrying   a 


228  INDUSTRIAL    MEDICINE    AND    SURGERY 

high  health  hazard  to  be  examined  at  least  once  a  month  for  the 
detection  of  any  ill  health  or  disease  resulting  from  their  employment. 

In  most  of  the  states,  requiring  notification  of  these  diseases,  they 
are  reported  to  the  state  board  of  health,  while  in  a«few  to  the  state 
department  of  labor.  In  order  that  such  reports  may  be  of 
definite  value  to  the  department  in  which  they  are  filed,  they  must 
be  uniform  and  complete  enough  to  permit  of  study  and  comparison 
in  order  that  future  legislation  governing  the  health  of  workers 
may  be  based  upon  evidence  deduced  from  them.  They  should  show 
the  nature  of  the  symptoms  of  the  existing  disease,  the  duration, 
time  of  onset,  prodromes,  age,  sex  and  previous  health  of  the  worker, 
a  full  account  not  only  of  the  specific  work  and  materials  concerned 
with  the  patients'  employment  but  also  the  general  nature  of  the 
employees'  hygienic  surroundings  should  be  included.  The  value  of 
such  reports  will  be  greatly  enhanced  by  the  adoption  of  a  uniform 
record  for  the  use  of  all  states,  which  will  be  of  great  aid  in  securing 
uniform  legislation  on  this  sub  j  ect.  Through  the  efforts  of  the  American 
Association  of  Industrial  Physicians  and  Surgeons  it  is  hoped  that  such 
a  uniform  history  record  may  be  voluntarily  adopted  by  all  physicians 
and  investigators. 

In  the  United  States  the  power  to  regulate  and  control  working 
conditions  except  as  they  affect  foreign  or  interstate  commerce 
directly  rests  with  the  individual  states  based  upon  their  "police 
power"^    and  the  ''authority  to  secure  the  public  welfare." 

Laws  requiring  the  reporting  of  occupational  diseases  are  all  of 
recent  origin.  Most  of  the  bills  passed  in  the  states  have  been  copies 
or  modifications  of  the  standard  bill  suggested  bythe  American  Associa- 
tion for  Labor  Legislation.  In  1911  California,  Connecticut,  IIH- 
nois,  Michigan,  New  York  and  Wisconsin  passed  laws  requiring  notifi- 
cation of  occupational  diseases.  Maryland  and  New  Jersey  enacted 
such  legislation  in  1912;  Maine,  Massachusetts,  Minnesota,  Missouri, 
New  Hampshire,  Ohio,  and  Pennsylvania  in  1913;  and  Rhode  Island 
in  1915.  The  Missouri  law  is  the  most  comprehensive  of  these: 
employees  engaged  in  manufacture  in  which  antimony,  arsenic,  brass, 
copper,  lead,  mercury,  phosphorus,  zinc,  their  alloys  or  salts  or  any 
poisonous  chemicals,  minerals,  acids,  fumes,  vapors,  gases  or  other 
substances  are  generated  or  handled  by  employees  in  harmful  quanti- 
ties or  under  harmful  conditions,  are  required  to  be  examined  at  least 
once  a  month  by  a  physician  to  ascertain  whether  there  exists  in  such 
employees  any  disease  due  or  incident  to  the  character  of  the  work 
in  which  they  are  engaged.  The  examining  physicians  are  within, 
twenty-four  hours  to  make  a  report  to  the  state  board  of  health  in 
triplicate  upon  blanks  furnished  by  the  state.  If  disease  incident  to 
^  Freud,  E. :  "Police  Power,"  pp.  3-7. 


HEALTH  HAZAEDS  IN  OCCUPATIONS  229 

occupation  is  found,  the  secretary  of  the  state  board  of  health  is  to 
send  one  copy  to  the  state  factory  inspector  and  one  to  the  superintend- 
ent of  the  factory  in  which  the  employee  is  supposed  to  have  contracted 
his  ailment. 

We  can  best  illustrate  methods  of  legislation  covering  occupational 
health  hazards  in  America  by  reference  to  recently  enacted  statutes 
in  a  few  of  the  industrial  states. 

Illinois. — "The  Health  Safety  and  Comfort  Act"  covers  the  regu- 
lations to  secure  adequate  ventilation  both  artificial  and  natural, 
work  rooms  and  proper  toilet  facilities  for  both  sexes,  the  disposal  of 
noxious  fumes,  gases,  and  vapors,  proper  regulation  of  temperature 
in  workshops  and  seats  for  women.  Another  statute  deals  with  the  use 
of  blowers  on  metal  polishing  and  grinding  machinery.  In  July,  1911, 
the  "Occupational  Disease  Act"  was  passed  requiring  the  installation 
by  employers  of  certain  standard  appliances  for  the  prevention  of 
occupational  diseases  especially  among  employees  exposed  to  poison- 
ing by  the  fumes  of  lead  or  other  metals  in  such  processes  as  the 
manufacture  of  brass  or  smelting  of  lead  and  zinc.  These  provisions 
were  adopted  as  a  result  of  the  investigations  and  report  of  the  Illinois 
Commission  on  Occupational  Diseases. 

In  this  state  the  duty  of  the  enforcement  of  these  laws  and  prose- 
cutions under  them  devolves  upon  the  chief  factory  inspector  and  his 
staff.  The  penalty  either  for  violating  the  law  or  obstructing  the  in- 
spectors is  a  fine  of  $10  to  $50  for  the  first  offense,  and  $25 
to  $200  for  later  offenses.  On  the  discovery  of  the  violation  of 
the  law  the  inspector  is  to  notify  the  manager.  It  is  further  required 
that  the  essential  text  of  this  law  in  various  languages  be  posted  in  all 
establishments  covered  by  the  statute.  Under  the  "Health  Safety 
and  Comfort  Act"  and  the  "Occupational  Diseases  Act,"  physicians 
and  dentists  are  employed  by  the  factory  inspector  to  make  daily 
investigations  and  personal  inspections  of  plants.  Some  research 
has  also  been  done  by  the  staff  as  to  the  effect  of  certain  metalHc  poi- 
sons on  animals.  Provision  is  made  for  routine  monthly  examination 
of  all  workers  exposed  to  the  danger  of  poisoning  by  metallic  dusts 
or  fumes,  by  physicians  paid  by  the  employer,  with  immediate  reports 
to  the  state  board  of  health,  who  in  turn  notifies  the  department  of  fac- 
tory inspection  of  any  cases  of  occupational  disease  found.  An  em- 
ployee, or  his  family,  has  the  right  of  action  for  damages  up  to 
$10,000  if  he  be  affected  by  metallic  poisoning  in  an  industry  where 
employers  have  not  fulfilled  the  requirements  of  the  law  as  to  pro- 
tective nieasures  and  examinations. 

Michigan. — Here  the  Governor  is  authorized  to  appoint  a  com- 
missioner of  labor  for  two  years  and  he  in  turn  may  appoint  factory- 
inspectors  and  assistants.     It  is  the  duty  of  this  commissioner  to  report 


230  INDUSTRIAL   MEDICINE    AND    SURGERY 

on  the  "moral  and  sanitary  conditions  of  the  laboring  classes  and  the 
productive  industries  of  the  state"  (Act  185,  Public  Acts  of  1909 
(amended  1911))  and  to  inspect  all  working  places.  The  hours  of 
labor  for  women  and  children,  and  employment  of  these  in  certain 
occupations  is  restricted;  provision  is  made  for  the  installation  of  fans 
for  dust  removal;  toilets  and  lavatories  are  required.  There  are  spe- 
cial requirements  for  seats  for  women,  factory  ventilation,  sanitary 
regulation  of  mines  and  of  work  in  tenement  houses.  Complaints 
of  neglect  of  the  law  are  to  be  made  to  justices  of  the  peace  or  magis- 
trates. Provision  is  made  for  the  reporting  by  the  local  boards  of 
health  of  contagious  and  infectious  diseases  to  the  factory  inspector 
of  the  commissioner  of  labor. 

Missouri. — As  was  mentioned  above  one  of  the  most  comprehensive 
statutes  in  the  United  States  providing  for  reporting  and  recording 
cases  of  occupational  diseases  is  in  effect  here.  In  June,  1913,  the  first 
''Occupational  Disease  Law"  was  put  in  force.  By  the  provisions 
of  this  law  it  is  the  duty  of  all  licensed  physicians  to  report  such  cases 
as  come  under  the  act  to  the  State  Board  of  Health  in  duplicate,  one 
copy  being  sent  to  the  manager  of  the  industry  employing  the  afflicted 
workman  and  one  to  the  factory  inspector's  office.  Provision  is  also 
made  for  hygienic  supervision  of  work  rooms,  special  work  clothing  to 
be  worn  by  employees  and  separate  eating  places  in  dangerous  trades, 
proper  drinking  water  and  drinking  fountains.  The  proper  measures 
for  inspection  and  enforcement  of  these  regulations  and  prosecution 
of  violators  by  the  state  factory  inspector  as  well  as  a  requirement 
for  the  posting  of  notices  of  the  provisions  of  the  law  are  included. 

Maryland. — In  1912^  a  state  department  of  health  was  established. 
The  statute  in  this  state  defines  and  describes  occupational  diseases 
and  requires  the  reporting  of  cases  found  by  physicians  to  the  state 
board  of  health.  This  body  is  empowered  to  call  upon  local  boards  of 
health  and  health  officers  for  aid  in  inspections  and  the  enforcement  of 
the  law.  A  system  of  warning  notices  is  required  to  be  posted  by 
employers. 

New  York. 2 — The  commissioner  of  labor  appointed  by  the  gov- 
ernor by  and  with  the  advice  and  consent  of  the  senate,  for  a  term  of 
office  of  four  years,  has  supervision  of  the  department  of  labor.  He 
appoints  all  officers  and  clerks  of  this  department.  One  of  the  three 
bureaus  in  the  department  is  that  of  factory  inspection  which  is  comprised 
of  a  chief  factory  inspector  and  staff  including  one  medical  inspector  of 
factories.  This  medical  inspector  makes  yearly  reports.  These  have 
contained  studies  of  different  industries  in  New  York  for  the  detec- 

1  Ch.  163,  Law  of  1912. 

2  New  York  State  Department  of  Labor  Ann.  Rep.  of  Commissioner  of  Labor 
1911-1912.     Labor  Laws  of  U.  S.,  p.  905  (Acts  of  1907). 


HEALTH  HAZARDS  IN  OCCUPATIONS  231 

tion  of  occupational  diseases.  Hygienic  exhibitions  for  public  instruc- 
tion have  been  prepared  by  the  bureau,  and  recommendations  made  for 
better  methods  of  ventilation  of  shops  and  removal  of  dust,  fumes, 
gas  and  vapors.  The  work  of  medical  inspection  in  this  state  is  of 
course  greatly  handicapped  by  its  limited  size. 

Ohio. — In  March,  1913,  legislation  was  enacted  requiring  physicians 
to  report  within  twenty-four  hours  from  the  time  of  attending  such 
patients,  cases  of  occupational  diseases  contracted  as  a  result  of  em- 
ployment, or  due  to  poisoning  from  lead,  phosphorus,  arsenic,  brass, 
wood  alcohol,  mercury,  or  their  compounds.  Considerable  latitude  is 
allowed  by  the  board  of  health  as  to  the  forms  of  reports  and  extent 
of  information  demanded.  Since  May,  1913,  Dr.  E.  M.  Hayhurst, 
who  was  one  of  the  medical  investigators  of  the  Illinois  Commission 
on  Occupational  Diseases,  has  been  in  charge  of  the  work  conducting 
a  ''survey  of  occupational  diseases"  for  the  state  board  of  health  pre- 
liminary to  the  drafting  recommendations  for  future  legislation  and 
administration.  In  the  board  of  health  of  Ohio  are  vested  powers  of 
supervision  of  all  matters  relating  to  the  preservation  of  the  life  and 
health  of  the  people.  "It  may  make  special  or  standing  orders  of 
regulations  for  preventing  the  spread  of  contagious  or  infectious  dis- 
eases   and  for  such  other  sanitary  matters  as  it  deems  best 

to  control  by  general  rule."  Violation  of  such  regulations  are  to  be 
prosecuted  in  the  courts  by  customary  procedures. 

Pennsylvania. — By  an  act  of  June  1,  1913,  the  commissioner  of 
labor  and  industry  is  appointed  by  the  governor  with  consent  of  the 
senate.  Provision  is  made  for  a  chief  medical  inspector  with  a  staff 
of  physicians  as  assistants  as  well  as  medical,  chemical,  and  civil 
engineers,  and  also  a  division  of  industrial  hygiene.  This  department 
has  done  excellent  work  under  Commissioner  Jackson,  assistant  com- 
missioner Palmer,  and  medical  director  Dr.  Francis  Patterson. 

Massachusetts. — In  June,  1912,  an  act  was  passed  to  establish  a 
state  board  of  labor  and  industries.  Prior  to  that  industrial  hygiene 
had  been  under  the  control  of  the  state  board  of  health.  The  new 
board  consists  of  one  employer,  one  laborer,  one  physician  and  one 
woman.  This  board  appoints  a  commissioner  of  labor.  In  this  board 
is  vested  the  power  to  investigate  labor  conditions,  hold  hearings, 
seek  expert  advice,  and  prosecute  violators  of  the  law,  and  the  duties 
formerly  exercised  by  the  police  and  health  department  in  relation  to 
the  enforcement  of  laws  governing  hygiene  in  the  industries.  This 
new  board  has  health  inspectors  who  are  required  to  be  medical  men, 
while  medical  men  are  also  employed  by  the  department  of  health  but 
have,  however,  no  authority  in  enforcing  laws  regarding  factory 
conditions. 

Wisconsin. — The  state  industrial  commission  is  empowered  to  make 


232  INDUSTRIAL   MEDICINE    AND    SURGERY 

effective  the  state  law  which  expresses  in  general  the  duty  of  employers 
to  protect  life,  health  and  safety  of  employees  and  the  duty  of  the  latter 
to  co-operate  in  carrying  out  this  purpose.  It  has  the  authority  to 
call  in  experts  in  hygiene  and  engineering  to  assist  in  the  establishment 
of  definite  standards  and  rules.  In  the  drafting  of  such  regulations 
employees  and  employers  have  a  right  to  be  heard.  This  method  of 
adopting  legislation  is  slow  and  depends  for  its  efficiency  entirely  upon 
the  type  of  men  appointed  to  the  commission. 

The  above  are  sufficient  examples  to  show  the  trend  of  legislation 
in  respect  to  industrial  hygiene  in  the  United  States. 

MUNICIPAL  HEALTH  BOARDS  AND  COMMISSIONERS 

In  America  the  functions  of  city  health  departments  have  been 
directed  toward  the  establishment  of  public  hygienic  conditions  in 
general  and  not  in  the  industries  specifically  or  in  particular.  Rarely 
have  municipal  authorities  attempted  to  study  or  regulate  working 
conditions  in  the  industries.^  It  is  interesting  to  note  that  in  1910  in 
New  York  in  one  group  of  trades,  that  of  the  garment  workers,  a  joint 
board  of  sanitary  control  comprised  of  representative  for  the  employers, 
workers,  and  the  piiblic  has  been  organized  to  establish  standards  of 
hygienic  conditions  and  enforce  them. 

LICENSING 

The  system  of  licensing  dangerous  occupations  gives  the  govern- 
ment an  additional  means  of  enforcing  factory  legislation  and  inspec- 
tion. By  this  system  special  requirements  must  be  fulfilled  and  laws 
governing  construction  and  equipment  must  be  adhered  to  before 
dangerous  industries  can  be  licensed.  It  is  always  easier  to  prevent 
than  cure  faulty  hygienic  conditions  and  this  system  of  licensing  after 
thorough  inspection  of  plans  and  specifications  in  vogue  in  foreign  coun- 
tries is  probably  destined  to  be  extended  to  the  dangerous  trades  by 
the  states  or  Federal  Government  of  the  United  States. 

SPECIAL  PREVENTIVE  MEASURES  FOR  WORKERS 

The  practical  measures  which  may  be  used  in  the  protection  of  work- 
ers against  trade  risks  involve  limitations  and  restrictions  of  three 
sorts,  (1)  upon  the  methods  of  handling  the  dangerous  materials,  (2) 
upon  the  period  of  exposure  to  the  harmful  action  of  these  materials, 
and  (3)  upon  the  persons  exposed.  These  are  seldom  applied  sepa- 
rately and  it  is  feasible  to  consider  the  methods  of  application  of  these 
limitations  as  they  can  be  applied  to  the  processes  involving  the  use 

^Wald,  Lillian  D.:  15th  International  Congress  on  Hygiene  and  Demography, 
Vol.  iii,  Pt.  ii,  p.  881. 


HEALTH  HAZARDS  IN  OCCUPATIONS  233 

of  various  dangerous  materials.  It  is  however  obvious  that  in  a 
consideration  of  the  third  group  it  is  desirable  to  select  for  employment 
in  a  dangerous  trade  persons  possessing  powers  of  resistance  and 
exclude  those  who,  because  of  predisposition  or  lowered  resistance,  are 
especially  susceptible  to  trade  poisoning.  Such  susceptibility  varies 
in  individuals  and,  as  discussed  above  in  the  case  of  lead,  in  the  two 
sexes. 

In  a  rough  way  such  a  selection  naturally  occurs  without  supervision 
since  those  susceptible  are  obliged  by  repeated  attacks  or  increasing 
disability  to  give  up  the  particularly  harmful  work.  From  the  stand- 
point of  industrial  economy  as  well  as  humanitarian  considerations 
such  a  method  of  selection  is  intolerable.  While,  unfortunately, 
exact  tests  for  susceptibility  applicable  to  applicants  for  work  by 
the  examining  physicians  are  at  present  lacking,  it  is  still  true  that 
industrial  physicians  may  acquire  an  aptitude  for  the  general  grouping 
of  applicants  for  work,  picking  the  robust  for  heavier  labor  and 
selecting  for  the  slightly  defective  or  poorly  muscled  various  less 
strenuous  occupations  which  will  not  put  a  special  strain  on  the 
weakest  part,  e.g.,  the  myopic  eye,  the  defective  heart  valve,  the 
broken  arches,  or  the  inguinal  canal  protected  by  inadequate  muscular 
development.  The  physician  engaged  in  this  work  is  governed 
by  considerations,  difficult  to  formulate,  in  the  choice  of,  or  exclusion 
from  certain  employments,  as  for  the  anemic,  the  worker  of  poor  lung 
power,  or  small  vital  capacity.  As  his  experience  in  such  work  grows, 
he  becomes  a  specialized  employee  most  valuable  to  the  plant. 

Further,  workers  engaged  in  industries  involving  a  high  health  risk 
or  who  possess  special  limitations  in  physical  strength  as  do  women 
and  children  should  not  be  kept  working  too  long  at  a  time.  This 
can  be  regulated  either  by  shortening  the  hours  of  labor  or  by  changes 
or  variations  in  the  type  of  labor.  In  1912  our  Federal  Government 
set  a  precedent  for  an  important  standard  by  enacting  legislation 
forbidding  contractors  on  federal  work  to  keep  men  at  work  longer 
than  eight  hours  in  one  day.  A  few  states  have  since  limited  the 
working  day  to  eight  hours  while  some  have  restricted  work  to  six 
days  a  week.  If  such  restrictions  are  important  for  labor  in  general 
they   are  doubly   urgent   for   dangerous   trades. 

An  example  of  the  limitation  of  tedious  work  for  the  adolescent 
is  that  of  Berne  where  no  girl  under  the  age  of  seventeen  may  be 
employed  at  a  tredle  machine  for  more  than  three  consecutive  hours 
a  day.  In  regard  to  night  work  nine  states  have  legislation  prohibiting, 
under  certain  conditions,  women  and  children  for  such  work.  Con- 
necticut, Massachusetts,  New  York,  Vermont  and  most  European 
countries  have  enacted  legislation  prohibiting  women  from  working 
for     fixed     periods    before    and    after    confinement.     Unfortunately 


234  INDUSTRIAL   MEDICINE    AND    SURGERY 

restrictions   barring  especially   susceptible  individuals  from  the  dan- 
gers of  industrial  poisoning  are  not  yet  widely  adopted. 

Periodical  medical  examinations  such  as  are  required  in  Illinois, 
Missouri,  New  Jersey,  Ohio  and  Pennsylvania  in  the  occupations 
where  high  health  hazards  exist  are  most  valuable  in  discovering  and 
weeding  out  the  physically  unfit  and  the  victims  of  industrial  poison- 
ings before  these  symptoms  present  a  permanently  disabling  or  handi- 
capping stage  of  these  disorders.  Such  work  presupposes  special 
training   and   experience    in   the   physician  employed  in  inspection. 

Further,  in  some  occupations  involving  the  chance  of  develop- 
ment of  sudden  acute  poisoning,  there  should  be  a  trained  staff 
of  fellow  employees  competent  to  recognize  the  earliest  symptoms  of 
poisoning  and  to  render  first  aid,  and  these  should  be  equipped  with  appH- 
ances  adequate  for  this  purpose.  In  addition  to  special  appUances 
needed  in  special  trades,  attention  is  directed  to  the  use  of  oxygen 
apparatus  as  a  means  of  life  saving.  For  rescue  work  in  poisonous 
atmospheres,  gas  masks  or  breathing  helmets  must  be  readily  available 
and  medical  assistance  be  easily  accessible. 

The  co-operation  of  the  worker  in  the  early  detection  and  examina- 
tion for  signs  of  intoxications  is  indispensable.  He  must  be  taught  the 
aim  and  purpose  of  preventive  measures  and  the  inestimable  importance 
of  his  own  scrupulous  care  in  enforcing  all  means  directed  toward  his 
defense  as  well  as  the  untoward  results  of  the  neglect  of  such  considera- 
tions. Among  the  various  methods  for  teaching  employees  are  lectures 
and  class  room  instruction  by  the  factory  or  union  physician,  the 
sanitary  engineer  or  other  members  of  departments  or  human  main- 
tenance; and  concise  instructions,  in  the  form  of  notices  or  illustrated 
placards,  handed  the  employees,  placed  in  their  pay  envelopes,  or  posted 
up  in  workrooms.  Often  the  most  perspicuous  type  of  "welfare 
advertising"  is  that  which  develops  the  generalized  from  the  specific 
by  citing  an  actual  case  of  an  employee  known  by  the  rest  of  the  work- 
ing force.  For  example,  John  Doe  is  described  as  a  case  of  "gassing" 
followed  by  an  analysis  of  the  methods  which  should  be  employed  to 
prevent  such  occurrences. 

Of  preventive  measures  applied  to  the  handling  of  poisonous 
material  those  are  of  prime  importance  which  protect  the  worker 
as  far  as  possible  from  coming  in  contact  with  the  poison.  This 
is  attained  (1)  by  wearing  suitable  clothing,  (2)  by  the  use  of  respi- 
rators or  protectors  against  inhaling  poisonous  materials,  and  (3) 
by  careful  cleanliness,  especially  before  partaking  of  food.  Overalls 
over  ordinary  clothing  are  not  sufficient  protection.  The  ordinary 
clothing  must  be  taken  off  before  the  commencement  of  the  day's 
work,  in  a  separate  dressing  room  apart  from  the  workroom,  with 
adequate  arrangements  for  bathing  thoroughly  before  the  ordinary 


HEALTH  HAZARDS  IN  OCCUPATIONS 


235 


clothes  are  resumed  at  night.  Working  suits  of  smooth,  washable 
material  must  be  put  on,  to  be  taken  off  again  before  the  midday  meal, 
and  before  leaving  work  at  night.  Where  direct  handling  of  poi- 
sonous substance  is  unavoidable,  impervious  gloves  may  have  to  be 
worn  but  this  depends  upon  the  possibility  of  skin  absorption  of 
the  particular  poison  involved. 

Protection  of  the  respiratory  organs  is  difficult  to  provide  for  and 
to  enforce.     Respirators  to  be  worn  over  the  nose  and  mouth,  or 


Fig.  37. — Illustrating  the  use  of  respirators  and  proper  shop  clothing  as  protection 
against  occupational  disease.     Munition  factory  in  France. 


head  helmets  for  use  where  fumes  or  dusts  are  more  abundant,  are 
varied  in  construction.  The  pressure  of  such  apparatus  on  the  face 
becomes  tiresome  and  where  they  must  be  worn  employees  must  be 
selected  who  caji  become  accustomed  to  their  use  as  many  men  never 
can. 

Regular  rinsing  of  the  mouths  (especially  before  meals  and  on 
leaving  work)  of  those  who  work  where  poisonous  substances  give 
off  dust  or  fumes,  is  of  utmost  importance.  Employees  handling 
extremely  poisonous  chemicals  should  be  required  to  bathe  before 
leaving  work  at  night  and  to  wash  the  hands  and  face  thoroughly 
before  the  midday  meal.  The  shower  bath  is  the  most  convenient  and 
time  saving  form  of  bathing.  The  taking  of  meals  and  the  use  of 
tobacco  in  workrooms  must  be  prohibited. 

The  maintenance  of  a  robust  health  and  fit  physical  condition 


236  INDUSTRIAL   MEDICINE    AND    SURGERY 

is  one  of  the  most  effective  means  of  protecting  the  worker  against 
the  health  hazards  pecuhar  to  the  industries.  It  is  continually  demon- 
strated in  chronic  industrial  poisoning  that  the  ill  fed,  poorly  nourished, 
asthenic,  or  anemic  worker  is  the  first  affected  and  the  earliest  to 
succumb.  The  problem  of  the  prohibition  of  the  use  of  alcohol 
to  men  exposed  to  industrial  poisoning  is  especially  pertinent  in  the 
case  of  plumbism  in  which  the  deleterious  effects  of  its  use  have 
been  most  carefully  studied. 

The  substitution  of  non-poisonous  for  the  poisonous  materials  and 
of  the  safe  for  the  dangerous  processes  is  the  joint  problem  of  the  phy- 
sician and  the  safety  engineer.  The  following  are  examples  of  some  of 
these  suggested  substitutions:  "wet"  methods  (watering  white  lead 
chambers,  grinding  pulp  lead,  polishing,  scraping,  and  finishing  painted 
work  with  oil,  damping  of  smelting  mixtures)  in  place  of  "dry"  meth- 
ods where  dust  is  evolved;  the  substitution  of  the  safety  for  the  phos- 
phorous match ;  replacing  the  tin  and  mercury  amalgum  by  the  nitrate 
of  silver  and  ammonia  process  in  silvering  mirrors;  electroplating 
instead  of  coating  objects  with  mercury  and  volatilizing  the  excess; 
enamehng  and  painting  with  leadless  instead  of  lead  enamels  and 
paints;  the  use  of  air  pumps  in  place  of  mercury  pumps  in  producing 
the  vacuum  in  incandescent  electric  lamps. 

Next  to  personal  cleanliness  the  most  important  consideration 
in  the  prevention  of  industrial  poisoning,  and  of  primary  importance 
in  the  prevention  of  ill  health  caused  by  dust  is  the  cleanliness  of  the 
workroom  and  purity  of  the  air.  Working  places  should  be  light  and 
lofty  with  floors  constructed  of  impervious  material  easily  cleaned, 
and  walls  lime  washed  or  painted  with  white  oil  paint.  Angles  and 
corners  should  be   rounded. 

The  necessity  of  maintaining  the  purity  of  the  air  of  the  work- 
room requires  as  a  minimum  of  air  space  per  person  10  to  15  cubic 
meters  and  this  should  be  exceeded  wherever  possible.  In  modern 
soundly  constructed  workrooms  the  "natural"  ventilation  from 
windows,  doors  and  the  porosity  of  building  material  will  not  supply 
the  necessary  volume  of  air  quickly  enough.  By  such  means  the  air 
is  rarely  renewed  in  less  than  one  to  two  hours.  In  workrooms, 
for  more  than  a  very  few  persons,  artificial  ventilation  becomes  im- 
perative. This  is  effected  by  special  openings  or  ducts  arranged  in 
the  room  so  that  either  (1)  fresh  air  is  propelled  into  the  room,  or  (2) 
by  exhaust  ventilation,  air  is  extracted  from  the  room.  The  agencies 
which  may  be  employed  to  produce  a  draft  in  ventilating  ducts  are 
(1)  by  utihzing  the  action  of  the  wind,  in  which  case  a  cowl  must  be 
fitted  to  the  exit  of  the  ventilating  duct;  (2)  by  heating  apparatus; 
(3)  by  heating  the  air  in  the  exhaust  ducts  as  for  instance  when  they 
are  lead  into  chimneys  or  furnace  flues;  (4)  by  the  use  of  fans  mechan- 


HEALTH  HAZARDS  IN  OCCUPATIONS  237 

ically  employed.  Where  there  is  any  considerable  amount  of  dust, 
or  the  danger  of  poisoning  is  present,  by  far  the  most  expedient  venti- 
lation is  by  power  fans  by  which  exact  regulation  of  the  purity  of  the 
air  can  be  calculated  and  assured  irrespective  of  differences  of  temp- 
erature, velocity  of  the  wind,  etc.  These  are  of  two  types,  the  pro- 
peller and  the  centrifugal.  The  first  type  has  curved  blades  set  at 
right  angles  in  the  duct  and  acts  upon  the  column  of  air  by  suction, 
moving  it  in  the  direction  of  the  action  of  the  fan.  A  low  pressure 
draft,  that  is  one  of  a  pressure  generally  less  than  15  mm.  of  water, 
is  produced;  the  air  traveling  at  a  slow  speed.  These  fans  are  especially 
suitable  for  general  ventilation  of  rooms  while  the  centrifugal  type, 
in  which  the  air  is  drawn  out  by  rapidly  moving  straight  blades 
through  openings  in  the  periphery  of  its  casing,  traveling  at  a  high  speed 
and  producing  a  pressure  not  lower  than  120  mm.,  is  especially  applicable 
to  the  local  exhaustion  of  dust  or  fumes  from  the  point  where  they  are 
produced. 

SPECIAL  REGULATIONS  FOR  THE  CHEMICAL  INDUSTRIES 

The  Sulphuric  Acid  Industry. — Hazards  of  two  kinds  are  encoun- 
tered here:  (1)  those  arising  from  the  escape  of  acid  gases  and  (2) 
those  endangering  the  men  entering  chambers,  towers,  and  con- 
tainers for  the  purpose  of  cleaning  these.  For  hygienic  as  well  as 
economic  reasons  the  whole  chamber  system  should  be  impervious 
to  gases.  The  escape  of  fumes  from  the  pyrites  furnace  is  accom- 
phshed  by  maintaining  a  negative  pressure  inside  by  fans.  Cinders 
from  the  furnaces  must  be  cooled  in  a  covered  place.  Rambousek 
says  that  the  acid  content  of  the  final  gases  can  be  reduced  to  0.1 
vol.  per  cent,  with  a  maximum  of  0.26  per  cent,  of  sulphur  dioxid. 
Cleaning  out  chambers  and  towers,  if  they  must  be  entered,  should 
be  done  by  men  equipped  with  breathing  apparatus.  One  German 
factory  has  the  following  regulations. 

"The  deposit  of  the  floor  of  wagons  or  tanks  shall  be  removed 
either  by  flushing  with  water  without  entering  the  tank  itself,  or  if 
the  tank  be  entered  the  deposit  is  to  be  scooped  out  without  addition 
of  water  or  dilute  soda  solution. 

"Flushing  out  shall  only  be  done  after  the  workmen  have  got  out. 

"Workmen  are  to  be  warned  every  time  cleaning  is  undertaken 
that  poisonous  gases  are  developed  when  the  deposit  on  the  floor  is 
diluted. 

"Acid  eggs,  further,  are  to  be  provided  with  a  waste  pipe  and  man- 
hole to  enable  cleaning  to  be  done  from  outside." 

Hydrochloric  Acid,  Salt  Cake,  and  Soda  Industries. — The  general 
principles  applicable  to  the  avoidance  of  acid  fumes  must  be  followed. 


238  INDUSTRIAL   MEDICINE    AND    SURGERY 

Proper  construction  prevents  the  escape  of  fumes  from  the  salt  cake 
pan  and  reverberating  furnaces.  The  following  regulations  are  in 
substance  those  which  have  been  in  effect  in  England  for  many 
years. 

The  salt  cake  pan  must  not  be  charged  when  overheated. 

Sulphuric  acid  shall  be  added  only  after  all  the  salt  has  been 
charged  and  the  door  shut. 

If  hydrochloric  acid  fumes  escape  at  the  door  when  the  Glover 
acid  flows  in,  the  flow  must  be  interrupted. 

All  doors  must  be  closed  while  work  is  in  progress. 

Definite  times  shall  be  fixed  for  withdrawal  of  the  salt  cake  in  order 
to  try  and  ensure  that  it  be  not  still  fuming,  but  should  this  be  the  case, 
cold  sulphate  of  soda  shall  be  sprinkled  over  it. 

A  slight  negative  pressure  should  be  maintained  in  the  furnace 
by  means  of  the  insertion  of  a  fan  in  the  gas  conduit  to  prevent  the 
escape  of  fumes.  The  fuming  salt  cake  is  best  cooled  in  ventilated 
receptacles. 

Bleaching  Powder,  Chlorin  and  Its  Compounds. — The  same  prin- 
ciples as  to  imperviousness  of  apparatus  and  maintenance  of  negative 
pressure  as  described  above  apply  here.  At  the  end  of  the  system 
the  last  traces  of  chlorin  gas  should  be  absorbed  by  a  tower  of  quick- 
lime or  series  of  bleach  chambers.  Production  of  chlorin  gas  elec- 
trolytically  is  the  least  dangerous  method.  Mechanical  handling 
of  bleaching  powder  is  far  more  hygienic  than  hand  labor. 

Nitric  Acid  and  Explosives. — Complete  imperviousness  and 
condensation  of  gases  is  feasible  and  should  be  insisted  upon.  Val- 
entines method  under  a  partial  vacuum  is  the  best  from  a  hygienic 
viewpoint.  Great  care  in  handling  and  packing  the  acid  is  required 
and  warnings  against  remaining  in  rooms  where  it  has  been  spilled 
should  be  posted.  The  rules  mentioned  above,  cleaning  wagons  and 
receptacles  for  sulphuric  acid,  apply  to  nitric  also.  The  rules  of 
the  Massachusetts  State  Board  of  Health  for  acid  manufacture  cover 
the  necessary  hygienic  precautions  admirably. 

In  the  nitrating  processes  in  explosive  manufacture,  the  apparatus 
must  be  hermetically  sealed  and  the  agitation  be  done  by  compressed 
air  or  mechanical  means  and  any  fumes  developed  exhausted  and 
condensed.  The  gases  evolved  from  nitroglycerin  are  especially 
dangerous.  The  attention  of  the  workers  must  be  drawn  to  this 
and  to  the  danger  of  contact  of  this  chemical  with  the  skin  or  of 
wearing  clothing  contaminated  with  it  away  from  the  factory.  In 
producing  gun  cotton  all  the  work  should  be  done  by  machinery 
and  the  fumes  exhausted.  Fulminate  of  mercury  production  re- 
quires exhaust  ventilation. 

Trinitrotoluene   (TNT)   Poisoning. — The  possibility  of  poisoning 


HEALTH  HAZARDS  IN  OCCUPATIONS  239 

from  TNT  has  been  recognized  for  several  years  but  as  a  result  of  the 
war  it  has  forged  to  the  front  as  one  of  the  most  dangerous  occupational 
poisonings  connected  with  munition  work.  The  poisonous  material 
in  TNT  is  composed  chiefly  of  one  of  three  isomeric  trinitrotoluenes, 
called  the  symmetrical  group,  because  the  three  NO2  groups  are 
symmetrically  arranged  on  the  toluene  nucleus.  The  commercial 
variety  contains  also  insignificant  quantities  of  the  other  two  isomers 
and  a  variable  percentage  of  mono-  and  dinitrotoluene,  together  with 
small  amounts  of  nitrated  methanes  and  other  substances. 

Dr.  Alice  Hamilton^  gives  an  excellent  review  of  the  causation 
and  prevention  of  this  type  of  poisoning,  based  on  the  work  done  in 
England  by  Dr.  Benjamin  Moore  and  his  assistants.  The  following 
conclusions  are  cited: 

"  1.  TNT  is  absorbed  through  the  skin,  and  that  is  the  only  channel 
of  absorption  which  is  of  any  practical  importance. 

"2.  Consequently  elaborate  systems  of  exhaust  ventilation  to  carry 
off  fumes  are  not  necessary,  for  there  is  no  case  on  record  of  poisoning 
from  TNT  fumes  alone.  The  wearing  of  respirators  is  not  advised, 
since  the  amount  of  dust  that  can  be  breathed  in  is  too  small  to  be 
harmful.  Dust  is  dangerous  only  as  it  falls  on  the  skin  or  clothes  or 
on  surfaces  that  must  be  handled. 

''3.  When  TNT  is  swallowed  deliberately  by  experimenters,  the 
effect  is  as  slight  as  when  the  same  amount  is  inhaled. 

"  4.  TNT  readily  makes  its  way  through  the  skin  and  is  absorbed, 
setting  up  in  susceptible  persons  a  slowly  increasing  intoxication. 

"5.  Therefore  the  prevention  of  TNT  poisoning  depends  on  two 
factors — first,  strict  cleanliness  of  the  factory  premises,  so  that  there 
will  be  as  little  actual  contact  with  TNT  as  possible,  and  second,  close 
watch  of  workers  to  eliminate  that  minority  which  has  a  low  resistance 
to  TNT.  Since,  however,  it  is  impossible  entirely  to  protect  the  skin 
from  contact  with  TNT  in  manufacturing  and  in  shell-filUng  opera- 
tions, the  importance  of  the  second  factor  becomes  evident.  In 
spite  of  the  best  efforts  to  do  away  with  all  skin  contamination  there 
will  be  inevitably  some  contact  with  the  poison,  and  though  the 
majority  of  workers  will  be  able  to  tolerate  the  small  amount  they 
absorb,  a  certain  amount  will  be  unable  to  resist  its  effects,  and  it  is 
this  group  of  workmen  that  must  be  discovered  and  removed  before 
actual  injury  has  taken  place. 

"  In  a  word,  the  prevention  of  TNT  poisoning  depends  on  cleanli- 
ness of  the  work  place  and  ever' watchful  medical  supervision." 

TNT  acts  on  the  blood,  changing  the  hemoglobin  into  a  mixture 
of  "  iVO-hemoglobin  and  methemoglobin."     Thus  the  altered  hemo- 

^  Industrial  Poisons  and  Diseases.  Monthly  Review.  United  States  Depart- 
ment of  Labor,  May,  1918. 


240  INDUSTRIAL   MEDICINE    AND    SURGERY 

globin  cannot  function  as  oxygen  carriers,  giving  the  symptoms  of  air 
hunger.  This  is  the  earhest  stage  of  TNT  illness  and  the  symptoms 
complained  of  are  breathlessness,  tightening  in  throat  and  chest,  dizzi- 
ness, drowsiness,  nausea,  and  abdominal  pains.  Cyanosis  frequently 
develops  in  this  stage  and  may  be  very  slight  or  extremely  marked. 
Marked  cyanosis  may  appear  while  the  patient  yet  feels  quite  well. 
A  marked  aplastic  anemia  originally  develops,  showing  a  decrease  in 
the  red  cells  to  1,500,000,  or  even  lower.  The  hemoglobin  is  reduced 
to  30  or  40  per  cent.     The  picture  is  that  of  a  pernicious  anemia. 

The  early  cases  of  TNT  sickness  present  almost  a  characteristic 
appearance.  "The  face  is  pale,  lacking  in  expression.  The  lips  have 
an  ashen  blue  color  and  the  same  color  is  seen  on  the  gums."  There 
may  be  a  faint  trace  of  yellow  in  the  whites  of  the  eyes,  the  rest  of 
the  skin  showing  no  jaundice.  When  these  are  observed  the  physi- 
cian should  question  the  worker  and  he  is  then  likely  to  be  told  of 
abdominal  pains,  dizziness,  sleepiness,  breathlessness,  headache  or 
nausea,  and  dark  colored  urine.  But  this  history  may  or  may  not  be 
given,  according  to  whether  the  worker  feels  like  resting  or  keeping 
on  with  work.  Dr.  Moore  of  England  states  that  the  physician  should 
patrol  the  plant  at  frequent  intervals,  familiarizing  himself  with  the 
workers  as  they  appear  normally,  and  thus  become  able  to  detect  those 
slight  changes  which  show  to  the  experienced  eye  the  beginning  of  ill 
health. 

In  the  serious  form  TNT  poisoning  causes  a  toxic  jaundice.  Dr. 
Moore  regards  both  jaundice  and  fatal  anemia  as  secondary  results  of 
the  same  action  of  the  poison  as  cause  symptoms  of  cyanosis.  When 
the  jaundice  begins  to  appear  it  is  quite  evident  that  the  bone  marrow 
and  liver  tissue  have  been  attacked  and  the  patient  has  reached  a 
dangerous  stage  of  poisoning.  This  is  usually  presented  by  signs  of 
cyanosis  and  if  these  cases  are  removed  from  the  hazardous  occupation 
in  the  early  stages  the  accumulated  poison  in  the  body  will  soon  be 
ehminated,  but  if  he  is  allowed  to  continue  at  work  within  a  short  time 
such  serious  pathological  changes  appear  that  the  cases  may  prove 
fatal. 

Prevention  of  TNT  poisoning  is  best  summed  up  by  Dr.  Alice 
Hamilton  as  follows: 

"  The  knowledge  that  the  main  absorption  occurs  through  the  skin 
of  the  hands  indicates  three  lines  of  action,  namely:  (1)  keeping  clean 
all  that  the  hands  can  touch;  (2)  protecting  the  hands;  (3)  detecting 
those  hands  which  are  permeable  and  keeping  the  owners  away  from 
TNT  work." 

Clothing  must  be  designed  to  protect  the  body  from  the  TNT  dust. 
For  women  workers  the  bloomers  with  the  legs  extending  down  over 
high  shoes  or  boots  and  tied  tightly  at  the  bottom  should  replace  skirts. 


HEALTH  HAZARDS  IN  OCCUPATIONS 


241 


Low  shoes  should  never  be  worn.  The  working  clothes  must  be  kept 
apart  from  the  home  clothing.  Washing  of  the  hands  and  face  with  a 
solvent,  such  as  a  mixture  of  the  oxylenes,  has  been  advocated.  Again, 
applying  protective  varnishes,  such  as  the  ''casein  varnish"  to  the 
skin  at  the  beginning  of  the  day's  work  and  removing  it  at  the  end  of 
the  day,  has  given  excellent  results.  Among  the  best  preventive 
measures  are  the  constant  medical  supervision  of  the  workers  in  order 
to  early  detect  and  remove  the  susceptible  persons,  and  the  plan 


Fig.  38. — A  TNT  factory  in  England. 


of  alteration  of  labor  whereby  TNT  workers  work  part  time  at  the 
hazardous  occupation  and  part  time  at  other  work,  preferably  out 
of  doors.  Considerable  objection  to  the  alteration  method  has  been 
raised  because  of  the  increased  number  of  persons  exposed  to  TNT 
poisoning,  and  the  decreased  efficiency  which  results  from  lack  of 
skill  on  the  part  of  many  of  the  force. 

Treatment  consists  of  removing  these  patients  at  once  from  the 
hazardous  occupation,  freeing  the  hands,  hair,  clothing,  and  all  other 
things  which  come  in  contact  with  the  person  from  the  TNT  dust.  It 
is  always  preferable  to  treat  such  patients  in  a  hospital.  These 
early  day  treatments  are  the  most  important  and  it  is  during  this 

16 


242  INDUSTRIAL   MEDICINE    AND    SURGERY 

stage  that  the  poison  can  be  ehminated.  Fresh  air,  fresh  vegetables, 
soda  bicarbonate  and  other  alkahes  are  indicated,  for  there  is  always 
an  acidosis  present.  The  bowels  must  be  kept  open  by  purgatives 
and  the  kidneys  flushed  by  normal  salt  solutions  per  rectum  or  other 
saline  mixtures..  No  patient,  once  subject  to  TNT  poisoning,  should 
be  allowed  to  remain  at  this  work. 

Fertilizers  and  Artificial  Manures. — All  grinding  of  phosphorite 
and  superphosphates  must  be  done  automatically  in  closed  apparatus. 
Hydrochloric  acid  is  evolved  in  dissolving  the  phosphorite  with  sul- 
phuric acid  and  it  must  be  exhausted  by  acid  proof  fans.  The  German 
Imperial  Regulations  for  all  manipulations  of  basic  slag  which  follow 
furnish  an  admirable  model: 

1.  Workrooms  in  which  basic  slag  is  crushed,  ground,  or  stored 
shall  be  roomy  and  so  arranged  as  to  ensure  adequate  change  of  air. 
Floors  shall  be  of  impervious  material  allowing  of  easy  removal  of  dust. 

2.  Preliminary  breaking  of  the  slag  by  hand  shall  not  be  done  in 
the  grinding  rooms,  but  either  in  the  open  air  or  in  open  sheds. 

3.  Slag  crushers,  grinding  mills,  and  other  apparatus  shall  be  so 
arranged  as  to  prevent  escape  of  dust  as  far  as  possible  into  the  work- 
rooms. They  shall  be  provided  with  exhaust  ventilation  and  means 
for  collecting  the  dust  if  this  cannot  be  done  in  the  absence  of  dust. 

4.  Arrangements  shall  be  made  whereby  barrows  conveying 
material  to  the  grinding  mills  shall  be  emptied  directly  into  partially 
hooded  hoppers  provided  with  exhaust  ventilation  so  as  to  prevent 
escape  of  dust  into  the  workrooms. 

5.  The  casing  and  joints  of  the  grinding  mills,  ducts,  dust  col- 
lectors and  sieves  shall  be  airtight;  if  leaks  are  noticed  they  must 
be  repaired  forthwith. 

6.  Ducts,  dust  collectors  and  sieves  shall  be  so  arranged  as  to 
enable  periodical  cleansing  to  be  undertaken  from  the  outside. 

7.  Repairs  of  the  plant  mentioned  in  Par.  5  in  which  workers 
are  exposed  to  inhalation  of  slag  dust  shall  be  intrusted  by  the  occupier 
only  to  such  workers  as  wear  respirators  supplied  for  the  purpose 
or  other  means  of  protecting  mouth  and  nostrils  such  as  wet  sponges, 
handkerchiefs,  etc. 

8.  Emptying  of  slag  powder  from  the  grinding  mills  and  dust 
collectors  and  transference  to  the  store  rooms  shall  only  be  done  in 
accordance  with  special  regulations  designed  to  minimize  dust. 

9.  Filling  slag  powder  into  sacks  from  the  outlets  of  the  mills, 
elevating  and  discharging  it  into  receptacles  shall  only  be  done  under 
efficient  exhaust  ventilation. 

10.  Sacks  in  which  the  powder  is  transported  and  piled  in  heaps 
shall  be  of  a  certain  defined  strength  to  be  increased  in  the  case  of 
sacks  to  be  piled  in  heaps  more  than  3}i  meters  in  height.     Special 


HEALTH  HAZARDS  IN  OCCUPATIONS  243 

rooms  separated  from  other  workrooms  shall  be  provided  for  storage  of 
slag  powder  in  sacks.  Only  the  sacks  representing  the  previous 
day's  production  may  be  stored  in  the  grinding  rooms. 

Basic  slag  in  powder  and  not  in  sacks  shall  be  kept  in  special 
storage  rooms  shut  off  entirely  from  other  workrooms.  No  person 
shall  enter  such  storage  rooms  when  they  are  being  filled  or  emptied. 
Discharging  the  contents  of  the  sacks  into -them  shall  be  done  under 
exhaust  ventilation. 

11.  The  floors  of  the  workrooms  described  in  Par.  1  shall  be 
cleaned  before  the  commencement  of  each  shift  or  in  an  interval 
during  each  shift.  No  person  except  those  engaged  in  cleaning  shall 
be  present  during  the  operation.  If  cleaning  is  effected  by  sweeping, 
the  occupier  shall  require  the  persons  doing  it  to  wear  the  respirators 
provided  or  other  protection  for  the  mouth  and  nose. 

12.  The  occupier  shall  not  permit  the  workers  to  bring  spirits  into 
the  factory. 

13.  A  lavatory  and  cloak  room  and,  separated  from  them  and  in  a 
part  of  the  building  free  from  dust,  a  meal  room  shall  be  provided. 
These  rooms  shall  be  kept  clean,  free  from  dust,  and  be  heated  during 
the  winter. 

In  the  lavatory  and  the  cloak  room,  water,  soap  and  towels  shall 
be  provided  and  adequate  arrangement  shall  be  made  for  keeping 
the  clothing  taken  off  before  commencing  work.  The  occupier  shall 
give  the  persons  employed  opportunity  to  take  a  warm  bath  daily 
before  leaving  work  in  a  bath  room  erected  inside  the  factory  and  heated 
during  the  winter. 

14.  No  woman  or  male  young  person  under  eighteen  years  of 
age  shall  work  or  remain  in  a  room  into  which  basic  slag  is  brought^ 

Persons  under  eighteen  years  of  age  shall  not  be  employed  in 
beating  sacks  which  have  contained  basic  slag. 

15.  No  person  employed  in  breaking  or  grinding,  emptying,  pack- 
ing, or  storing  basic  slag,  shall  work  more  than  ten  hours  daily. 

There  shall  be  intervals  during  working  hours  amounting  in  the 
aggregate  to  two  hours,  one  of  them  lasting  at  least  an  hour.  If 
duration  of  employment  daily  is  limited  to  seven  hours  with  never 
longer  than  four  hours  work  without  an  interval,  only  one  interval  of 
at  least  one  hour  is  required. 

16.  For  work  mentioned  in  Par.  15,  no  person  shall  be  employed 
without  a  certificate  from  an  approved  surgeon  stating  that  he  is  free 
of  disease  of  the  lungs  and  not  alcoholic.  The  occupier  shall  place  the 
supervision  of  the  health  of  the  workers  under  a  sutgeon  who  shall 
examine  them  at  least  once  a  month  for  signs  of  disease  of  the  res- 
piratory organs  and  for  alcoholism.  Workers  engaged  in  theoperations 
mentioned  in  Par.   15  shall  be  suspended  from  emplojniient  when  the 


244  INDUSTRIAL    MEDICINE    AND    SURGERY 

surgeon  suspects  such  illness  or  alcoholism.  Those  showing  marked 
susceptibility  to  the  effect  of  basic  slag  dust  shall  be  permanently 
suspended. 

17.  A  health  register  shall  be  kept  in  which  shall  be  entered  the 
precise  employment,  duration  of  work,  and  state  of  health  of  the  persons 
employed. 

18.  The  occupier  shall  obtain  a  guarantee  from  the  workers  that  no 
alcohol  or  food  shall  be  taken  into  the  workrooms. 

Fumes  given  off  in  the  preparation  of  hydrofluoric  acid  must  be 
collected  in  leaden  coolers  and  that  which  escapes  requires  to  be  absorbed 
by  a  water  spray  in  the  towers.  The  apparatus  must  be  impervious 
and  kept  under  a  slight  negative  pressure. 

Chromium  Compounds.^ — ^In  Austria,  Germany  and  England  suitable 
provisions  are  in  force  for  the  prevention  of  chrome  ulceration  and  other 
affections  caused  by  contact  with  chromates  in  such  occupations  as 
those  in  bichromate  works,  chemical  factories,  dyeing,  tanning,  and 
wood  staining,  calico  and  wall  paper  printing,  painting,  etc.  These 
provisions  require  that  dust  producing  processes  must  be  carried 
on  away  from  the  general  workrooms;  chromates  must  be  crushed 
in  hermetically  sealed  apparatus  as  far  as  possible;  working  clothes, 
caps,  and  respirators  must  be  supplied  to  employees.  They  must 
also  be  provided  with  soap,  towels,  nail  brushes,  bathing  facilities, 
cloak  rooms  and  lunch  rooms.  Every  employee  must  furnish 
a  certificate  stating  that  he  has  no  skin  disease  or  open  wounds. 
Daily  examinations  of  the  hands  and  arms  is  enjoined.  Monthly 
medical  examinations  are  also  required  and  any  employee  presenting 
signs  of  chrome  poisoning  or  ulceration  is  suspended  until  free  from 
this.  Rules  for  personal  hygiene  are  posted;  smearing  the  skin  with 
oil  or  vaseline  is  recommended.  The  use  of  impervious  gloves  is 
necessary  in  some  processes.  By  the  English  law  foremen  are  re- 
quired to  report  to  their  managers  the  names  of  workers  failing  to 
comply  with  the  rules  for  personal  hygiene. 

Petroleum  and  Benzin. — Crude  petroleum  and  the  fractions  first 
distilled  from  it  affect  the  skin  injuriously.  Wetting  of  the  skin 
should  be  avoided  and  careful  cleansing  enjoined.  Those  exposed 
to  the  gases  escaping  from  oil  wells  should  be  provided  with  ''smoke 
helmets."  Petroleum  tanks  should  be  thoroughly  aired  before  they 
are  cleaned  and  they  should  be  entered  only  by  workers  equipped  with 
bathing  apparatus.  Apparatus  such  as  used  in  the  rubber  industry 
and  in  chemical  cleaning  establishments  containing  petroleum  or 
benzin  should  be  airtight.  The  prevention  of  poisoning  from  fumes 
of  benzol  or  benzin  lies  in  adequate  ventilation  so  that  the  fu;mes 
are  so  diluted  as  to  be  harmless  even  to  those  who  have  a  special 
susceptibility  to  their  action.     Artificial  ventilation  with  air  exhaust 


HEALTH  HAZARDS  IN  OCCUPATIONS  245 

preferably  with  a  down  draft  (since  these  fumes  are  heavy)  must  be 
installed  where  concentrated  fumes  are  evolved.  Specially  suscepti- 
ble persons  must  be  excluded  from  any  industries  involving  the  exten- 
sive use  of  benzin.  The  substitution  of  carbon  tetrachlorid  or  other 
less  poisonous  substances  for  benzin  can  be  effected  in  many  processes. 

Phosphorus. — Since  the  use  of  white  phosphorus  in  making 
matches  has  been  prohibited  in  the  United  States  since  July  1,  1913, 
no  detailed  description  of  hygienic  regulations  in  this  trade  are  neces- 
sary. The  danger  of  poisoning  exists  also  in  the  extraction  of  phos- 
phorus, in  the  production  of  coal  tar  dyes,  and  the  making  of 
phosphor  bronze.  The  number  of  workers  exposed  in  these  processes 
is  very  small.  The  ordinary  precautions  previously  described  governing 
the  handling  of  toxic  substances  should  be  applied  here. 

Carbon  Bisulphid. — England  forbids  work  longer  than  five  hours  a 
day  in  rooms  where  carbon  bisulphid  is  being  used  in  vulcanizing 
rubber,  and  no  food  may  be  eaten  there.  Employees  must  be  exam- 
ined monthly  and  records  kept  of  such  examinations.  In  Germany^ 
since  March  1,  1902,  more  exacting  methods  are  in  force  with  provision 
for  special  ventilators,  devices  to  prevent  the  escape  of  fumes,  cloak 
room  and  washing  facilities,  and  monthly  examination.  Provisions 
for  preventive  methods  by  the  various  rubber  works  in  America  vary 
greatly,  some  being  very  thorough.  The  same  care  should  prevail  also 
in  the  other  industries  in  which  carbon  bisulphid  is  used,  e.g.,  in 
preparation  of  cellulose  for  artificial  silk  and  in  cleaning  estabHsh- 
ments.  In  various  extracting  processes  and  in  vulcanizing,  from 
a  hygienic  standpoint,  benzin,  chlorid  of  sulphur  or  carbon  tetra- 
chlorid are  much  to  be  preferred  to  carbon  bisulphid. 

Production  of  Tar,  Coke,  and  Gas.' — Imperviousness  of  the  work- 
ing system  of  the  illuminating  gas  factory  especially  of  the  retorts  and 
correct  regulation  of  pressure  is  absolutely  necessary  to  prevent 
needless  loss  of  life  through  gas  poisoning.  Special  precautions 
are  furthermore  necessary  in  operations  with  gas  purifying  materials 
which  so  often  contain  cyanogen.  These  consist  in  carrying  off 
injurious  gases  by  suitable  ventilating  apparatus  and  their  condensa- 
tion without  discharging  them  into  the  atmosphere  so  as  to  be  a 
menace  to  health  in  the  vicinity.  "  Quenching"  the  coke  also  removes 
obnoxious  fumes.  The  same  regulations  in  regard  to  rendering  all 
apparatus  airtight  and  sufficiency  of  exhaust,  apply  to  coke  ovens. 
They  also  apply  to  the  distillation  of  washing  oils. 

Power  Gas  Works. 2— The  following  regulations  from  the  Aus- 
trian Ministerial  Decree  of  December  2,  1903,  cover  the  important 
considerations. 

^  Rambousek :  "industrial  Poisoning,"  p.  271. 
2  Rambousek:  "industrial  Poisoning,"  p.  277. 


246  INDUSTRIAL    MEDICINE    AND    SURGERY 

In  mixed  gas  installations  (Dowson,  water  gas)  of  the  older  sys- 
tem, the  way  in  which  the  gas  is  produced  causes  the  whole  apparatus 
and  pipes  to  be  under  slight  negative  pressure,  because  the  steam 
required  for  the  process  must  be  blown  into  the  generator.  In  these 
works,  therefore,  a  small  special  steam  boiler  is  required,  also  a  gas 
receiver  to  store  the  gas. 

In  more  modern  suction  generator  gas  installations  the  piston  is 
used  to  suck  in  steam  and  air  as  well  as  the  gases  arising  in  the 
generator  and  to  draw  them  into  the  motor  cylinder.  Thus  the  whole 
system  is  kept  in  a  condition  of  slight  negative  pressure  during  the 
process.  While  the  suction  generator  gas  system  is  working,  only  so 
much  gas  is  produced  as  the  motor  uses  for  the  time  being,  so  that  with 
this  system  there  is  no  greater  store  of  gas  than  is  requisite. 

In  such  an  installation  the  following  rules  should  be  borne  in  mind : 

1.  All  the  apparatus  (gas  pipes,  valves,  etc.)  must  be  constructed 
and  maintained  in  a  completely  impervious  condition.  Any  water 
seals  especially  which  may  be  in  use  must  receive  attention. 

2.  Precautions  must  be  taken  to  prevent  the  gases  from  the  gener- 
ator passing  into  the  coolers  and  purifiers  when  the  engine  is  at  rest. 

3.  Care  is  to  be  taken  when  the  apparatus  is  at  rest  to  prevent 
any  possible  subsequent  escape  of  gas  into  the  room  where  the  appa- 
ratus is  installed. 

4.  The  return  of  explosive  gas  out  of  the  gas  engine  into  the  gas 
pipe  by  failure-  to  ignite  or  other  accident,  must  be  made  impossible. 

5.  The  apparatus  through  which  the  generator  is  charged  must 
possess  a  tightly  fitting  double  valve  to  prevent  escape  of  gas  into 
the  room  during  charging. 

6.  The  -pipes  for  conducting  away  the  unpleasantly  smelling 
bituminous  constituents  in  the  water  mixed  with  sulphuretted  hydro- 
gen from  the  scrubbers  must  not  communicate  with  the  workroom. 

7.  Precautions  must  be  taken  to  minimize  the  danger  during  the 
cleaning  of  the  generator  (removal  of  ashes  and  slag) . 

8.  All  stop-cocks  and  valves  are  to  be  so  arranged  that  their  posi- 
tion at  any  tilne  (open  or  shut)  is  clearly  visible  from  the  outside. 

9.  Purifiers  with  a  capacity  greater  than  2  cubic  meters  must  be 
provided  with  '  applicances  which  make  possible  thorough  removal 
of  gas  before  they  are  opened. 

10.  The  gas  washing  and  cleaning  apparatus  and  pipes  are  to  be 
fitted  with  gauges  indicating  the  pressure  existing  in  them  at  any 
moment. 

11.  When  a  suction  gas  plant  is  first  installed  and  also  at  those 
times  when  there  is  no  gas  in  the  pipes  and  plant  between  the  gen- 
erator and  the  engine,  gas  must  be  blown  in  until  all  air  is  expelled 
before  the  engine  is  set  going. 


HEALTH  HAZARDS  IN  OCCUPATIONS  247 

12.  During  the  cleaning  of  apparatus  and  pipes  which,  when  in 
action,  contain  gas,  the  rooms  must  be  thoroughly  ventilated. 

13.  Rooms  in  which  suction  gas  plant  is  installed  must  be  of  such 
a  height  that  all  the  plant  and  its  connections  can  be  easily  reached 
for  cleaning,  etc.,  and  be  capable  of  such  free  ventilation  as  to  render 
impossible  an  accumulation  of  gas. 

14.  These  rooms  must  be  separated  from  living  rooms  by  a  wall 
without  any  openings  in  it.  Emanations  also  must  be  prevented  as 
far  as  possible  from  entering  into  living  or  working  rooms  situated 
over  the  gas  engine. 

15.  Erections  of  apparatus  for  generating  and  purifying  suction 
gas  in  cellars  shall  only  be  allowed  if  specially  effective  ventilation  is 
provided  by  natural  or  mechanical  means. 

Acetylene  Gas. — -The  Prussian  Ministerial  Decree  of  November 
2,  1897,  establishes*  the  following  regulations  regarding  workers  in 
acetylene  gas  installations : 

1.  Preparation  and  condensation  of  acetylene  on  the  one  hand, 
and  liquefaction  on  the  other,  must  be  carried  on  in  separate 
buildings. 

2.  If  the  pressure  employed  for  condensation  of  the  gas  exceeds 
eight  atmospheres,  this  work  must  take  place  in  a  room  set  apart  for 
the  purpose. 

3.  Rooms  in  which  acetylene  is  prepared,  condensed,  or  liquefied 
shall  not  be  used  as,  nor  in  direct  connection  with,  living  rooms. 
They  must  be  well  lighted  and  ventilated. 

4.  The  carbide  must  be  kept  in  closed  watertight  vessels,  so  as 
to  ensure  perfect  dryness  and  only  such  quantities  shall  be  taken  out 
as  are  needed.  The  vessels  must  be  kept  in  dry,  light,  well  ventilated 
rooms;  cellar  rooms  may  not  be  used  for  storage  purposes. 

5.  Crushing  of  carbid  must  be  done  with  the  greatest  possible 
avoidance  of  dust.  Workers  are  to  be  provided  with  respirators 
and  goggles. 

6.  Acetylene  gasometers  must  be  fitted  up  in  the  open  air  or  in 
a  well  ventilated  room  separated  from  the  gas  generator.  Every  gas 
receiver  must  have  a  water  gauge  showing  the  pressure  in  the  receiver. 

7.  Between  the  gasometer  and  receiver  a  gas  purifier  must  be  pro- 
vided so  as  to  remove  impurities  (phosphoretted  hydrogen,  arseni- 
uretted  hydrogen,  carbon  bisulphid,  ammonia,  etc.) 

8.  Condensation  of  acetylene  gas  at  a  pressure  exceeding  ten 
atmospheres  shall  only  be  done  in  combination  with  cooling. 

Anunonia. — In  the  production  of  ammonia  and  ammonium  salts 
the  combination  of  ammoniacal  vapors  with  sulphuric  acid  gives 
rise  to  dangerous  gases  among  them  some  containing  sulphuretted 
hydrogen  cyanogen  compounds.     The  same  rules  as  to  imperviousness 


248  INDUSTRIAL    MEDICINE    AND    SURGERY 

and  exhaust  ventilation  as  in  other  chemical  processes  above  mentioned 
should  be  enforced. 

Tar  Products. — Tar  products  from  coal  tar  distillation  necessitate 
the  same  precautions.  Only  cold  pitch  and  asphalt  may  be  stored 
in  open  vats,  all  cooling  products  being  enclosed  in  ''receivers." 
The  injurious  gases  from  the  stills  containing  ammonia  and  sulphur 
compounds  should  be  either  led  into  the  furnace  or  subjected  to 
purification  by  lime  or  oxid  of  iron  for  the  recovery  of  sulphur  or 
ammonia.  The  following  directions  are  applied  since  1904  in  England 
to  the  distillation  of  tar  for  the  production  of  naphtha  light  oil,  creosote 
oil  and  pitch. 

1.  During  the  process  of  cleaning,  every  tar  still  should  be  com- 
pletely isolated  from  adjoining  tar  stills  either  by  disconnecting  the 
pipe  leading  from  the  swan  neck  to  the  condenser  worm,  or  by  discon- 
necting the  waste  pipe  fixed  to  the  worm  end  or  receiver.  Blank 
flanges  should  be  inserted  between  the  disconnections.  In  addition, 
the  pit  discharge  pipe  or  cock  at  the  bottom  of  the  still  should  be 
disconnected. 

2.  Every  tar  still  should  be  ventilated  and  allowed  to  cool  before 
persons  are  allowed  to  enter. 

3.  Every  tar  still  should  be  inspected  by  the  foreman  or  other 
responsible  person  before  any  workman  is  allowed  to  enter. 

4.  The  inspecting  foreman  on  first  entering  any  tar  still  or  tank, 
and  all  persons  employed  in  tar  stills  or  tanks  in  which  there  are  no 
cross  stays  or  obstructions  likely  to  cause  entanglement,  should 
be  provided  with  a  belt  securely  fastened  around  the  body  with  a  rope 
attached,  the  free  end  being  left  with  two  men  outside  whose  sole 
duty  should  be  to  watch  and  draw  out  any  person  appearing  to  be 
affected  by  gas.  The  belt  and  rope  should  be  adjusted  and  worn  in 
such  a  manner  that  the  wearer  can  be  drawn  up  head  foremost  and 
through  the  manhole  and  not  across  it. 

5.  A  bottle  of  compressed  oxygen,  with  mouthpiece,  should  be 
kept  at  all  times  ready  for  use;  and  printed  instructions  as  to  the  use 
of  this  bottle,  and  the  method  to  be  employed  for  resuscitation  by 
means  of  artificial  respiration  should  be  kept  constantly  aflSxed. 
A  draft  of  such  instructions  is  appended. 

6.  A  supply  of  suitable  chemical  respirators  properly  charged 
and  in  good  condition  should  be  kept  ready  for  use  in  case  of  emergency 
arising  from  sulphuretted  hydrogen  or  certain  poisonous  gases.  (Gran- 
ules of  carbon  saturated  with  a  solution  of  caustic  soda  readily  absorb 
sulphuretted  hydrogen  and  may  be  used  for  charging  respirators.) 

7.  The  use  of  naked  lights  should  be  strictly  prohibited  in  any 
portion  of  the  works  where  gas  of  an  inflammable  nature  is  liable  to 
be  given  off. 


HEALTH  HAZARDS  IN  OCCUPATIONS  249 

8.  Each  still  should  be  provided  with  a  proper  safety  valve  which 
should  at  all  times  be  kept  in  efficient  working  condition. 

Gassing.  Symptoms. — The  first  symptoms  are  giddiness,  weakness 
in  the  legs,  and  palpitation  of  the  heart.  If  a  man  feels  these  he  should 
at  once  move  into  fresh  warm  air,  when  he  will  quickly  recover  if 
slightly  affected.  He  should  avoid  exposure  to  cold.  He  should 
not  walk  home  too  soon  after  recovery;  any  exertion  is  harmful. 

First  Aid. — Remove  the  patient  into  fresh  warm  air.  Send  for  the 
oxygen  apparatus.  Send  for  a  doctor.  Begin  artificial  breathing  at 
once  if  the  patient  is  insensible  and  continue  it  at  least  for  half  an 
hour,  or  until  natural  breathing  returns.  Give  oxygen  at  the  same 
time  and  continue  it  after  natural  breathing  returns. 

Artificial  Breathing  (Schafer  Method). — Place  the  patient  face 
downward.  Kneel  at  the  side  of  the  patient  or  astride  of  him  and 
place  your  hands  flat  in  the  small  of  his  back  with  thumbs  nearly 
touching,  and  the  fingers  spread  out  on  each  side  of  the  body  over  the 
lowest  ribs. 

Then  promote  artificial  breathing  by  leaning  forward  over  the 
patient  and,  without  violence,  produce  a  firm,  steady,  downward 
pressure.  Next  release  all  pressure  by  swinging  your  body  backward 
without  lifting  your  hands  from  the  patient. 

Repeat  this  pressure  and  relaxation  of  pressure  without  any  marked 
pause  between  the  movements,  about  fifteen  times  a  minute,  until 
breathing  is  established. 

Use  of  Oxygen  Cylinder.' — Open  the  valve  gradually  by  tapping  the 
lever  key  (which  must  first  be  extended  to  its  full  length)  with  the 
wrist  until  the  oxygen  flows  in  a  gentle  stream  from  the  mouthpiece 
into  the  patient's  mouth.  The  lips  should  not  be  closed  around  the 
mouthpiece.  The  nostrils  should  be  closed  during  breathing  in, 
and  opened  during  breathing  out. 

If  the  teeth  are  set,  close  the  lips  and  one  nostril.  Let  the  conical 
end  of  the  mouthpiece  slightly  enter  the  other  nostril  during  breathing 
in,  and  remove  it  for  breathing  out. 

Coal  Tar  Colors  and  Organic  Dye-stuffs. — Much  has  been  done  in 
the  last  few  years  to  clear  up  the  misconceptions  as  to  the  dangers 
attending  the  production  of  anilin  and  other  coal  tar  colors.  The 
raw  products  themselves,  benzin,  toluidin,  etc.,  produce  the  greatest 
number  of  poisonings.  The  manufacture  of  the  intermediate  groups^ 
especially  nitro  compounds  is  also  dangerous.  The  subsidiary  sub- 
stances, especially  chlorin  and  other  acids  are  injurious.  In  purify- 
ing the  raw  material,  e.g.,  benzin,  distillation  and  cooling  apparatus 

'  Grandhomme:  "Weyls  Handb.  d.  Arbeiterkrankh., "  Jena,  1908  p.  104. 
Curschmann:  "Actes  deu  II  Congress  Internal  des  Maladies  Profession  elles 
Brussels,"  1910. 


250  INDUSTRIAL    MEDICINE    AND    SURGERY 

must  be  impervious.  Dangerous  solvents  such  as  pyridin  must  be 
used  in  closed  chambers.  In  the  nitrating  operations  poisonous 
nitrous  fumes  escape,  while  arseniuretted  hydrogen  escapes  when  re- 
duction is  accomplished  by  means  of  tin  and  sulphur  dioxid  or  sulphu- 
retted hydrogen  in  sulphonating  unless  the  apparatus  is  tightly  closed. 
These  injurious  fumes  should  be  burned,  neutralized,  or  absorbed 
and  disposed  of.  The  contact  of  workers  with  the  poisonous  anilin 
is  difficult  to  avoid  entirely  and  the  general  rules  for  personal  hygiene 
for  chemical  workers  must  be  scrupulously  obeyed. 

The  dangers  arising  from  poisonous  dusts  in  dye  works  have  been 
mentioned  under  injurious  dusts. 

PREVENTIVE  MEASURES  IN  SMELTING  AND  METAL 
HANDLING  TRADES 

When  furnaces  leak  because  the  walls  are  not  airtight  and  proper 
negative  pressure  is  not  maintained  injurious  gases,  principally  carbon 
monoxid,  sulphur  dioxid  and  hydrocarbons  escape.  Entering  flues 
for  cleaning  or  repairing  should  be  done  only  by  those  equipped  with 
breathing  apparatus.  In  roasting  operations  furnaces  are  now  largely 
worked  mechanically.  The  use  of  chlorin  compounds  in  extraction 
of  metals  such  as  silver  or  copper  from  ores  causes  the  evolution  of 
chlorin  and  hydrochloric  fumes  which  should  be  absorbed  in  special 
towers  while  metallic  fumes  should  be  dealt  with  by  special  condensers 
and  ventilators. 

Iron.^ — The  use  of  a  cupola  bell  opened  at  intervals  mechanically 
when  charging  is  necessary,  allows  the  poisonous  but  valuable  gases 
from  the  blast  furnace  to  pour  out,  be  conducted  away,  and  utiHzed. 
The  gases,  the  most  dangerous  o^  which  is  perhaps  sulphuretted  hydro- 
gen, which  escapes  during  tapping  and  slag  running  should  be  collected 
by  hoods  and  carried  off.  In  the  blowing  operation  by  the  Bessemer 
process  the  dark  smoke  arising  out  of  the  converter  should  be  drawn 
off  by  flues. 

In  the  transport  of  ferrosilicon  the  following  police  regulations  of 
the  Prussian  Minister  of  Trade  (September  29,   1910)  are  valuable: 

1.  The  ferrosilicon  must  be  packed  in  watertight  cases  of  wood  or 
metal, 

2.  On  the  cases  must  be  inscribed  legibly  and  indelibly  "Ferro- 
silicon.    To  be  kept  dry.     With  care. " 

3.  It  must  be  delivered  dry  and  in  dry  cases. 

4.  The  cases  must  be  stored  in  aif^  places  (on  the  boat)  protected 
from  the  wet. 

Dr.  Copeman^  as  a  result  of  his  inquiry  in  the  cases  of  poisoning 

'  On  the  Nature,  Uses,  and  Manufacture  of  Ferrosilicon,  1909. 


HEALTH  HAZARDS  IN  OCCUPATIONS  251 

on  the  steamer  Aston  has  suggested  the  following  regulations  which 
should  be  made  international: 

1.  Ferrosilicon  should  not  be  sent  out  from  the  works  immediately 
after  manufacture,  but  after  being  broken  up  into  pieces  of  the  size 
in  which  it  is  usually  sold,  should  be  stored  under  cover,  but  exposed 
to  the  air  as  completely  as  possible,  for  at  least  a  month  before  being 
dispatched  from  the  works. 

2.  Manufacturers  should  be  required  to  mark  in  bold  letters  each 
barrel  or  other  parcel  of  ferrosilicon  with  the  name  and  percentage 
grade  (certified  by  chemical  analysis)  of  the  material;  the  name  of 
the  works  where  it  is  produced ;  the  date  of  manufacture  and  date  of 
dispatch. 

3.  The  carriage  of  ferrosilicon  on  vessels  carrying  passengers  should 
be  prohibited.  When  carried  on  cargo  boats  it  should,  if  circumstances 
permit,  be  stored  on  deck.  If  it  be  considered  necessary  to  store  it 
elsewhere  the  place  of  storage  should  be  capable  of  being  adequately 
ventilated,  and  such  place  of  storage  should  be  cut  off  by  airtight 
bulkheads  from  the  quarters  occupied  by  the  crew  of  the  vessel. 

4.  This  regulation  should  apply  to  the  transport  of  ferrosilicon 
on  river  or  canal  barges  as  well  as  on  sea-going  vessels. 

5.  Storage  places  at  docks  or  at  works  where  ferrosilicon  is  used 
should  have  provision  for  free  access  of  air,  and  should  be  situated 
at  a  distance  from  workrooms,  mess  rooms,  offices,  etc. 

Lead.^ — All  measures  both  personal  and  general  which  have  been 
mentioned  in  the  general  discussion  of  the  prevention  of  industrial 
poisoning  should  be  put  into  practice  in  the  protection  of  the  worker 
against  the  most  widespread  of  all  slow  industrial  poisonings.  Per- 
sonal hygiene  is  as  important  as  proper  factory  conditions.  Workers 
in  lead  should  be  carefully  selected  under  medical  supervision  and  all 
should  be  excluded  who  present  signs  of  any  disease  which,  associated 
with  plumbism,  would  be  especially  dangerous,  such  as  all  forms  of 
tuberculosis,  alcoholism,  epilepsy,  hysteria  or  any  other  tendency 
to  mental  diseases,  "rheumatism,"  or  diseases  of  the  kidney  or  cardio- 
vascular apparatus.  Women  and  young  persons  should  be  excluded 
from  such  work.  Alternation  of  employment  and  short  working 
hours  are  especially  beneficial  to  workers  exposed  to  the  danger  of 
plumbism. 

The  early  diagnosis  of  lead  poisoning  is  best  accomplished  by 
periodic  examination  of  employees  and  on  the  appearance  of  the  first 
signs  they  should  be  transferred  to  some  other  work. 

Suitable  nourishing  food  and  avoidance  of  alcohol  are  of  prime 
importance. 

In  a  number  of  cases  substitution  is  impractical  but  wherever 
possible  non-poisonous  or  less  poisonous  substitutes  should  be  used  in- 


252  INDUSTRIAL   MEDICINE    AND    SURGERY 

stead  of  lead;  for  example,  the  substitution  of  carborundum  for  lead 
discs  in  polishing  precious  stones,  leadless  glaze  in  potteries  in  place 
of  lead  glaze,  beds  free  of  lead  in  various  industries  instead  of  lead 
beds.  The  attempts  to  find  suitable  substitutes  for  lead  colors, 
particularly  white  lead,  have  thus  far  not  been  rewarded  with  entire 
success. 

Attempts  have  been  made  to  introduce  soaps  containing  alkahn 
sulphids  into  the  lead  industries  for  use  in  the  lavatories  for  the  purpose 
of  converting  the  soluble  lead  on  the  worker's  skin  into  the  compara- 
tively insoluble  black  lead  sulphid. 

The  type  of  regulation  by  the  governments  of  continental  European 
countries  is  well  exemplified  by  the  following: 

Decree  of  the  President  of  the  French  Republic  (April  23,  1908) 
relating  to  certain  industries  in  which  lead  is  used 

1.  In  the  lead  industries  hereinafter  mentioned,  viz.:  smelting, 
cupellation  of  argentiferous  lead,  manufacture  of  accumulators, 
glass-making,  manufacture  and  use  of  lead  enamels,  manufacture  of 
pottery,  decoration  of  porcelain  or  faience,  ceramic  chromo-htho- 
graphy,  manufacture  of  lead  alloys,  oxids,  salts  and  colors,  employers, 
directors  or  managers  are  required,  apart  from  the  general  measures 
prescribed  by  the  Decree  of  the  29th  of  November,  1904,  to  take 
special  measures  for  protection  and  health  as  set  forth  in  the  follow- 
ing sections. 

2.  Lead  melting  pots  shall  be  erected  in  an  airy  place  separated 
from  the  other  workrooms. 

Hood  or  other  means  for  the  effectual  removal  of  fumes  shall  be 
provided : 

(a)  Over    the    openings  for  the  run  of  lead  and  slag  in  lead 

smelting, 
(6)  Before  the  furnace  doors  in  the  manufacture  of  lead  oxids. 
(c)  Above  the  pots  for  melting  lead  or  its  alloys,  in  the  other 

industries  enumerated  in  section  1. 

3.  All  work  with  oxids  and  other  compounds  of  lead  capable  of 
producing  dust  shall  be  done  as  far  as  possible  when  in  a  damp  con- 
dition. 

When  this  work  cannot  be  done  in  the  presence  of  water  or  other 
Hquid,  it  shall  be  carried  out  by  mechanical  means,  in  covered  airtight 
apparatus. 

If  it  is  impossible  to  conform  to  the  requirements  of  either  of  the 
first  two  paragraphs  of  this  section,  the  work  shall  be  done  under  a 
strong  draught  so  arranged  that  the  harmful  products  may  be  inter- 
cepted by  apparatus  suitably  placed. 


HEALTH  HAZARDS  IN  OCCUPATIONS  253 

Finally,  if  none  of  these  systems  is  possible  the  workmen  shall 
be  supplied  with  respirators. 

4.  Oxids  and  other  compounds  of  lead,  whether  dry  or  damp,  in 
suspension  or  solution,  shall  not  be  handled  with  the  bare  hands.  The 
employer  shall  at  his  own  expense  provide  the  workers  in  these  opera- 
tions with  either  gloves  made  of  impervious  material  such  as  india 
rubber,  or  suitable  appliances,  and  shall  cause  them  to  be  kept  in  good 
repair  and  frequently  cleaned. 

5.  Tables  on  which  these  products  are  handled  shall  be  covered 
with  some  impervious  material,  kept  in  a  perfectly  watertight  con- 
dition. 

The  same  requirement  applies  to  the  floors  of  the  workrooms  which 
shall  also  be  kept  damp. 

The  floors  shall  be  slightly  sloped  toward  a  watertight  receptacle 
for  collecting  the  lead  substances  which  are  washed  down. 

The  work  shall  be  so  arranged  that  there  shall  be  no  splashing. 
The  tables,  floors  and  walls  shall  be  washed  at  least  once  a  week. 

6.  Without  prejudice  to  the  requirements  of  Section  3,  the  grind- 
ing and  mixing  of  lead  products,  and  the  use  of  them  in  dusting  shall 
be  effected  in  special  places  with  active  ventilation. 

If  the  materials  cannot  be  damped,  the  workers  shall  be  provided 
with  respirators. 

7.  Pottery  shall  not  be  dipped  with  bare  hands  in  solutions  con- 
taining litharge,  red  lead,  galena  or  white  lead  in  suspension. 

8.  No  food  or  drink  shall  be  brought  into  the  works. 

9.  Employers  shall,  at  their  own  expense,  provide  and  maintain 
for  the  use  of  the  workers,  overalls  or  clothing  for'  use  during  work 
only,  in  addition  to  gloves  and  respirators. 

10.  In  a  part  of  the  building  separated  from  the  workrooms,  there 
shall  be  provided  for  the  use  of  the  workers  exposed  to  lead  dust  or 
fumes,  a  cloak  room  and  lavatory  kept  in  good  order,  provided  with 
basins  or  taps  in  sufficient  number,  a  plentiful  supply  of  water,  soap 
and  a  towel  for  each  worker  replaced  at  least  once  a  week. 

The  cloak  room  shall  be  provided  with  cupboards  or  drawers  with 
locks  or  padlocks  the  ordinary  clothing  being  kept  apart  from  the 
working  clothes. 

11.  A  warm  bath  or  shower  bath  shall  be  provided  each  week  for 
the  workers  exposed  to  lead  dust  or  fufnes. 

A  warm  bath  or  shower  bath  shall  be  provided  every  day  after 
work,  for  each  worker  employed,  either  in  emptying  or  cleaning  the 
condensing  chambers  and  flues,  in  repairing  furnaces  in  lead  works, 
in  carrying  lead  corrosions  from  the  bed  in  white  lead  factories,  in 
packing  red  lead,  in  grinding  lead  enamels  and  in  dry  dusting. 

12.  Employers  are  required  to  exliibit,  in  a  conspicuous  position 


254  INDUSTRIAL    MEDICINE    AND    SURGERY 

in  the  works,  regulations  imposing  on  the  workers  the  following 
obligations : 

To  use  the  appliances,  gloves,  respirators,  and  working  clothes 
placed  at  their  disposal. 

Not  to  bring  into  the  works  either  food  or  drink. 

To  pay  great  care  before  each  meal,  to  the  cleanliness  of  the  mouth, 
nose  and  hands. 

To  take  the  baths  weekly  or  daily  as  provided  in  Section  11. 

13.  The  Minister  of  Labor  may,  by  order  made  with  the  advice 
of  the  Consultative  Committee  for  Arts  and  Manufactures,  exempt  an 
establishment  for  the  specified  period  from  all  parts  of  the  require- 
ments of  Regs.  2,  5  and  6  in  any  case  where  it  is  found  that  observ- 
ance of  these  requirements  is  practically  impossible,  and  that  the 
health  and  safety  of  the  workers  are  assured  by  conditions  at  least 
equivalent  to  those  prescribed  in  the  present  Order. 

14.  Subject  to  additional  postponements  which  may  be  granted 
by  the  Minister  in  pursuance  of  Section  6  of  the  Act  of  12th  June, 
1893  (as  amended  by  that  of  11th  July,  1903),  the  delay  required  for 
the  carrying  out  of  the  alternations  necessitated  by  the  present  decree 
is  limited  to  one  year  from  the  date  of  its  publication. 

15.  The  Ministry  of  Labor  is  charged  with  the  administration  of 
this  Decree. 

This  Decree  was  supplemented  by  further  noteworthy  additions 
requiring   medical   supervision  in  lead  industries  as  follows: 

Decree  of  December   28,   1909,    Organizing     Medical   Service  in 
Industries  Exposing  the  Workers  to  risk  of  Lead  Poisoning 

1.  In  premises  in  which  the  processes  enumerated  in  Regula- 
tion 1  of  the  Decree  of  April  23,  1908,  are  carried  on  medical  attendance 
as  prescribed  below  shall  be  provided. 

2.  A  surgeon  appointed  by  the  occupier  shall  examine  the  workers 
and  enter  the  results  of  examination  required  in  Regulations  3  and  4. 
The  examinations  shall  be  paid  for  by  the  occupier. 

3.  No  person  shall  be  employed  in  work  mentioned  in  Regulation  1 
of  the  Decree  of  April  23,  1908,  without  a  certificate  from  the  surgeon 
stating  that  he  is  free  from  symptoms  of  lead  poisoning  and  of  ill- 
ness which  might  render  him  specially  susceptible. 

4.  No  worker  shall  remain  at  the  same  employment  unless  the 
certificate  is  renewed  one  month  after  commencement  of  employment 
and  subsequently  at  quarterly  intervals. 

In  addition  to  the  periodical  examination,  the  occupier  shall  give 
an  order  on  the  surgeon  to  every  workman  declaring  himself  to  be  ill 
from  his  employment  or  who  desires  to  undergo  medical  examination. 


HEALTH  HAZARDS  IN  OCCUPATIONS  255 

5.  A  special  Register  open  to  the  Factory  Inspector  shall  be  kept 
containing    the   following   particulars   of   each   worker: 

(1)  Dates  and  duration  of  absence  on  account  of  illness  of  any 
kind. 

(2)  Dates  of  medical  certificates  for  such  illness,  the  notes 
made  by  the  surgeon  and  the  name  of  the  surgeon  fur- 
nishing them. 

(3)  Instructions  given  by  the  appointed  surgeon  in  pursuance 
of  Regulations  3  and  4  above. 

Lead  Smelting. — All  flues,  furnaces  and  other  apparatus  in  this 
industry  should  be  as  airtight  as  possible  and  efficient  exhaust  ven- 
tilation should  be  provided  wherever  lead  dust  or  fumes  are  gener- 
ated. Lead  smelting  even  under  the  most  propitious  circumstances 
is  a  dangerous  occupation  and  personal  hygiene  among  workers  must 
be  encouraged  in  every  way  possible.  The  following  instructions  for 
smelters  are  issued  by  the  Institute  for  Industrial  Hygiene  of  Frank- 
furt. 

How   does   lead   poisoning   arise? 

The  danger  of  lead  poisoning  in  lead,  spelter  and  other  smelting 
premises  can  be  avoided  if  due  care  is  observed. 

Lead  poisoning  occurs  when  lead  enters  the  system.  This  takes 
place  by  breathing  dust  and  fumes  containing  lead,  or  by  eating  and 
drinking,  smoking,  snufT  taking  and  tobacco  chewing  if  food  or  tobacco 
is  taken  into  the  mouth  with  dirty  hands  and  dirty  face  and  beard. 

No  one  is  immune  from  lead.  Lead  accumulates  in  the  body  of 
careless  persons  and  he  who  is  not  sick  to-day  can  be  so  to-morrow  or 
after  weeks  or  months. 

How  can  plumbism  be  avoided? 

All  smelters  must  observe  cleanliness.  In  this  respect  they  should 
see  to  the  following  points: 

1.  It  is  to  their  interest  to  see  that  the  exhaust  ventilation  is  kept 
in  order  and  that  the  special  rules  or  regulation  are  exactly  followed. 
Further,  special  clothing  should  be  worn,  the  mouth  and  nose  should 
be  covered,  and  the  floors  sprinkled. 

2.  It  is  especially  important  that  in  intervals  and  at  the  close 
of  work  the  mouth,  face,  beard,  and  hands  should  be  carefully  cleaned. 
Food  should  not  be  eaten  or  the  premises  left  without  putting  on  fresh 
clothes  and  thoroughly  washing  or,  still  better,  bathing.  When  drink- 
ing, the  edge  of  the  drinking  glass  should  not  be  fingered  with  dirty 
hands.  Especially  important  is  it  that  the  teeth  should  be  cleaned 
and  the  mouth  washed  out. 

3.  During  work  smoking,  snuff  taking,  and  tobacco  chewing, 
which  invariably  convey  lead  into  the  mouth,  should  be  given  up, 
as  it  is  impossible  to  prevent  the  hands  getting  contaminated  with  lead. 


256  INDUSTRIAL    MEDICINE    AND    SURGERY 

Lighting  the  pipe  with  glowing  lead  ashes  is  in  the  highest  degree 
dangerous  from  the  risk  of  inhaling  lead  fume.  The  body  must  be 
strengthened  to  withstand  the  action  of  lead.  Moderation  in  drinking, 
especially  avoidance  of  spirits,  should  be  observed.  Alcohohc  subjects 
succumb  to  lead  poisoning  much  more  readily  than  the  temperate. 

Food  should  be  abundant  and  rich  in  fat,  for  example,  milk  and 
bacon.  Thick  soups  are  excellent  before  work.  Work  should  never 
be  begun  on  an  empty  stomach.  And  lastly,  as  much  fresh  air  as  pos- 
sible. Walking  athletics,  work  in  the  garden  and  field  will  help  to 
keep  off  many  an  attack.  If  anyone  thinks  that  he  is  suffering 
from  lead  poisoning  he  should  at  once  in  his  own  and  in  his  family's 
interest  see  the  doctor  of  his  sick  club. 

The  following  rules  are  noteworthy: 

German  Imperial  Regulations  for  Lead  Smelting  Works  Dated 

June  16, 1905 

general  regulations 

1.  Workrooms  in  which  lead  ores  are  roasted,  sintered,  or  smelted, 
pig  lead  produced  and  submitted  to  further  treatment,  distillation  of 
rich  lead  (bullion  cupellation)  litharge,  red  lead,  or  other  oxids  of 
lead  prepared,  ground  or  sieved,  stored  or  packed,  or  zinc  skimmings 
distilled,  shall  be  roomy,  high,  and  so  arranged  that  a  sufficient  con- 
stant exchange  of  air  takes  place.  They  shall  be  provided  with  a 
level  and  solid  floor  to  allow  of  easy  removal  of  dust  by  a  moist  method. 

The  walls  shall  be  smooth  so  as  to  prevent  collection  of  dust; 
they  shall  be  either  washed  down  or  lime  washed  at  least  once  a 
year. 

Provided  that  this  shall  not  apply  in  the  case  of  calcining  sheds  with 
woodened  walls. 

2.  An  abundant  supply  of  good  drinking  water,  protected  against 
contamination  from  dust,  shall  be  provided  for  the  workers  on  the 
furnaces  and  smelting  pots,  and  in  such  close  proximity  to  them  that 
they  can  obtain  it  at  any  time  without  having  to  go  into  the  open 
air. 

Arrangements  for  sprinkling  the  floors  shall  be  provided  near  the 
furnaces.  The  floors  of  the  rooms  mentioned  in  paragraph  1  shall 
be  wet  cleansed  at  least  once  daily. 

3.  Prepared  (i.e.,  concentrated)  lead  ores  and  leady  smelting 
products,  unless  moist,  shall  not  be  crushed  except  in  an  apparatus 
so  arranged  as  to  prevent  as  far  as  possible  penetration  of  dust  into 
the  workrooms. 

Provided  that  this  shall  not  apply  to  calcined  material  from 
converters. 

Sacks  in  which  lead  ores  and  materials  containing  lead  have  been 


HEALTH    HAZARDS    IN    OCCUPATIONS  257 

packed  shall  not  be  freed  from  dust  and  cleaned  except  in  a  dust  proof 
apparatus  or  by  washing. 

4.  Materials  containing  lead  for  charging  the  blast  furnaces, 
if  they  are  oxids  and  form  dust,  shall  be  damped  before  they  are  mixed 
with  other  materials,  stocked  on  the  feeding  floor,  or  charged  into  the 
blast  furnaces, 

5.  Dust,  gases,  and  lead  fumes,  escaping  from  furnaces,  converters, 
tapping  spouts,  tapping  pots,  drain  sump,  slag  pots,  slag  cars,  or 
slag  channels,  and  from  glowing  residues  taken  from  the  furnaces, 
shall  be  caught  as  near  as  possible  to  the  point  of  origin  and  removed 
harmlessly. 

Dust  collecting  chambers,  flues,  as  well  as  furnaces  which  have 
been  "blown  down,"  shall  not  be  entered  by  workmen  unless  suffi- 
ciently cooled  and  ventilated. 

SPECIAL  REGULATIONS  FOR  SUCH  PARTS  OF  A  FACTORY   WHERE  LEAD 
COLORS  ARE  PREPARED 

6.  In  grinding,  sieving  and  packing  dry  leady  materials,  in  charg- 
ing, and  empying  litharge  and  red  lead  furnaces,  in  collecting  the  red 
lead  and  similar  operations  in  which  leady  dust  is  developed,  exhaust 
arrangement  shall  be  provided  for  preventing  the  entrance  of  dust 
into  the  workrooms. 

7.  Apparatus  producing  leady  dust  if  their  construction  and  man- 
ner of  use  does  not  effectually  prevent  evolution  of  dust,  shall  have 
all  cracks  protected  by  thick  layers  of  felt  or  woolen  material,  or 
by  similar  means,  so  as  to  prevent  the  entrance  of  dust  in  to  the 
workrooms. 

Apparatus  of  this  character  shall  be  provided  with  arrangements 
for  preventing  compression  of  air  in  them.  They  shall  only  be  opened 
when  the  dust  in  them  shall  have  completely  settled,  and  they  are 
absolutely  cool. 

SPECIAL  ARRANGEMENTS  IN  FORCE  FOR  THE  DISTILLATION  OF  ZINC  SKIMMINGS 

8.  Proposed  new  furnaces  for  the  distillation  of  zinc  skimmings 
(for  which  according  to  Paragraphs  16  and  25  of  the  Industrial  Code 
a  special  permission  is  required)  shall  be  so  arranged  that  (1)  there 
shall  be  at  least  a  clear  space  of  ten  feet  in  front  of  the  charging 
opening;  (2)  any  passages  under  the  distillation  rooms  shall  be 
roomy,  at  least  11/^  feet  high  in  the  center,  light  and  airy, 

9.  Dust,  gases,  and  fumes  arising  from  the  zinc  skimmings  dis- 
tillation furnaces  shall  be  collected  as  near  as  possible  to  the  point 
of  origin,  and  carried  outside  the  smelting  room. 

The  entrance  of  gases  from  the  fires  into  the  smelting  room  shall 
be  prevented  as  far  as  possible  by  suitable  arrangements  for  drawing 
them  off, 

17 


258  INDUSTRIAL    MEDICINE    AND    SURGERY 

10.  Sieving  and  packing  of  by-products  obtained  in  the  distillation 
of  zinc  skimmings  (poussiere,  flue  dust)  shall  not  be  done  except  in 
a  special  room  separated  from  the  other  workrooms,  and  complying 
with  the  requirements  of  Regulation  1. 

Sieving  shall  only  be  done  in  an  apparatus  so  constructed  that 
dust  shall  not  escape. 

EMPLOYMENT  OF  WORKERS 

11.  Women  and  young  persons  shall  not  be  employed  or  permitted 
in  rooms  mentioned  in  Regulation  1,  in  flue  dust  chambers,  or  dust  flues, 
or  in  the  removal  of  flue  dust. 

12.  No  person  shall  be  newly  employed  in  rooms  mentioned  in 
Regulation  1,  in  flue  dust  chambers,  or  dust  flues,  or  in  the  transport 
of  flue  dust,  without  a  certificate  of  fitness  from  the  surgeon  appointed 
by  the  higher  authorities. 

These  certificates  shall  be  collected  and  shown  to  the  Factory 
Inspector  and  Appointed  Surgeon  on  request. 

13.  No  person  shall  be  employed  in  charging  blast  furnaces  apart 
from  mere  laboring  work  on  the  floors,  for  more  than  eight  hours 
daily.  The  same  shall  apply  in  the  case  of  workmen  employed  in 
the  inside  of  furnaces  when  cool,  or  in  emptying  flue  dust  chambers, 
or  dust  flues  which  contain  wet  flue  dust. 

No  person  shall  be  employed  in  cleaning  out  from  inside  flue  dust 
chambers,  or  dust  flues  containing  dry  flue  dust  for  more  than  four 
hours  daily;  and  including  emptying  and  work  of  transport  of  this 
kind  altogether  no  longer  than  eight  hours  daily. 

Other  workers  in  rooms  specified  in  Regulation  1  shall  not  work 
more  than  ten  hours  in  twenty-four,  exclusive  of  meal  times. 

Exception  to  this  is  allowed  in  the  case  of  those  workers  who  are 
employed  for  the  purpose  of  weekly  change  of  shift,  and  for  whom 
exception  as  to  Sunday  employment  is  permitted  by  Imperial  Decree. 

CLOTHING,  OVERALLS,  -LAVATORY  ACCOMMODATIONS,  ETC. 

14.  The  occupier  shall  provide  for  all  persons  employed  in  cleaning 
out  flue  dust  chambers,  dust  flues,  repairing  of  cooled  furnaces,  grind- 
ing, sieving  and  packing  of  litharge,  red  lead,  or  other  lead  colors, 
complete  suits  of  working  clothes,  including  caps  and  respirators. 

15.  Work  with  lead  salts  in  solution  shall  not  be  done  except 
by  workers  who  either  grease  their  hands  or  are  provided  with  im- 
permeable gloves. 

16.  The  suit  of  clothes,  or  overafls,  provided  in  Regulations  14 
and  15,  respirators  and  gloves,  shall  be  provided  in  sufficient  amount 
and  in  proper  condition.  The  occupier  shall  see  that  these  are  always 
suitable  for  their  purpose,  and  are  not  worn  except  by  those  workers 


HEALTH  HAZARDS  IN  OCCUPATIONS  259 

for  whom  they  are  intended;  and  that  they,  at  stated  intervals  (the 
overalls  at  least  once  a  week,  the  respirators  and  gloves  prior  to  use), 
are  cleaned,  and  during  the  time  that  they  are  not  in  use  are  kept  in  a 
place  specially  reserved  for  each  article. 

17.  A  lavatory  and  cloak  room  shall  be  provided  for  the  use  of 
the  workman  in  a  part  of  the  building  free  from  dust.  Separate 
from  it  there  shall  be  a  dining  room.  These  rooms  must  be  kept  free 
from  dust  and  be  warmed  during  the  winter. 

In  a  suitable  place  provision  shall  be  made  for  warming  the  workers' 
food. 

Water,  soap,  and  towels,  and  arrangements  for  keeping  separate 
the  overalls  from  other  clothing  taken  off  before  the  commencement 
of  work  shall  be  provided  in  sufficient  amount  in  the  lavatory  and 
cloak  room. 

The  occupier  shall  afford  opportunity  for  persons  engaged  in 
cleaning  out  flue  dust  chambers,  dust  flues,  and  the  cooled  furnaces, 
to  take  a  bath  daily  after  the  end  of  the  work,  and  for  those  handling 
oxids  of  lead,  at  least  once  a  week,  during  working  hours  inside  the 
works.     The  bath  room  shall  be  warmed  during  the  winter. 

18.  The  occupier  shall  place  the  supervision  of  the  health  of  the 
workers  in  the  hands  of  a  surgeon  appointed  by  the  higher  authorities 

•for  this  purpose,  whose  name  shall  be  sent  to  the  Inspector  of  Factories. 
The  surgeon  shall  examine  the  workers  at  least  once  a  month  in  the 
factory,  with  a  view  to  the  detection  of  symptoms  of  lead  poisoning. 

The  occupier  shall  not  employ  persons  suspected  by  the  surgeon 
of  having  contracted  lead  poisoning  in  the  processes  mentioned  in 
Regulation  1  or  in  cleaning  out  flue  dust  chambers,  dust  flues,  or 
furnaces  when  cold,  or  transport  of  the  flue  dust,  until  they  are  quite 
well.  Those  who  appear  peculiarly  susceptible  shah  be  permanently 
suspended  from  working  in  these  processes. 

19.  The  Health  Register  shall  be  shown  to  the  Factory  Inspector 
and  Appointed  Surgeon  on  demand.  (Similar  to  Regulation  15  of 
Smelter  Regulations.) 

20.  The  occupier  shall  require  the  workers  to  subscribe  to  the 
following  condition: 

(1)  Food  must  not  be  taken  into  the  workrooms.  Meals 
may  only  be  taken  outside  the  workrooms. 

(2)  Workmen  must  only  enter  the  meal  room  to  take  their 
meals  or  leave  the  factory,  after  they  have  taken  off 
their  overalls  and  carefully  washed  their  face  and  hands. 

(3)  Workmen  must  use  the  overalls,  respirators  and  gloves  in 
those  workrooms  and  for  the  particular  processes  for  which 
they  are  given  them. 

(4)  Cigar  and  cigarette  smoking  during  work  is  forbidden. 


260  INDUSTRIAL   MEDICINE    AND    SURGERY 

(5)  A  bath  in  the  factory  must  be  taken  every  day  at  the 
close  of  their  work  by  those  engaged  in  the  emptying  and 
cleaning  of  flue  dust  chambers,  flues,  and  furnaces  when 
cold,  and  by  those  employed  on  oxids  of  lead  once  a  week. 

Provided  that  this  shall  not  apply  in  the  case  of  workmen  exempted 
by  the  appointed  surgeon. 

Workers  contraventing  these  orders  will  be  liable  to  dismissal 
without  further  notice. 

21.  In  every  workroom,  as  well  as  in  the  cloak  room  and  meal 
room,  there  shall  be  posted  up  by  the  occupier,  in  a  conspicuous  place 
and  in  clear  characters,  a  notice  of  these  Regulations. 

The  occupier  is  responsible  for  seeing  that  the  requirements  of 
Regulation  20  (1)  is  obeyed.  He  shall  make  a  manager  or  foreman 
responsible  for  the  precise  carrying  out  of  Regulation  20  (1),  (2)  and 
(5).  The  person  thus  made  responsible  shall  see  to  the  carrying  out 
of  the  regulation  and  for  the  exercise  of  necessary  care  as  prescribed 
in  Paragraph  151  of  the  Factory  Act. 

22.  No  work  in  a  lead  smelting  works  shall  be  commenced  until 
notice  of  its  erection  has  been  sent  to  the  Factory  Inspector.  After 
receipt  of  the  notice  he  shall  personally  visit  to  see  whether  the  arrange- 
ments are  in  accordance  with  these  regulations. 

23.  These  regulations  come  into  force  on  the  1st  of  January,  1906. 
Where  structural  alterations  are  necessary  for  the  carrying  out 

of  Regulations  1,  6  (1),  6,  9,  10  and  17,  the  higher  authorities  may 
allow  an  extension  of  time  to  a  date  not  later  than  January  1st,  1908. 

If  it  seems  necessary  on  strong  grounds  of  public  interest  the 
Council  (Bundesrath)  may  extend  the  time  in  particular  works  until 
the  1st  of  January,  1913,  and  until  then  allow  exceptions  from  the 
regulations  as  regards  Regulation  13  (1)  and  (2). 

The  following  brief  synopsis  is  fairly  representative  of  the  English 
and  German  regulations  for  the  smelting  of  metals,  tinning  of  hollow 
ware,  dyeing  of  yarn  with  lead  chromate,  vitreous  enameling,  and 
rules  for  white  lead  and  earthenware. 

Definitions. — In  these  Regulations  "lead  process"  means  pasting, 
casting,  lead  burning,  or  any  work  involving  contact  with  dry  com- 
pounds of  lead. 

Any  approval  given  by  the  Chief  Inspector  of  Factories  in  pursuance 
of  these  Regulations  shall  be  given  in  writing,  and  may  at  any  time 
be  revoked  by  notice  in  writing  signed  by  him. 

Duties  of  Occupier 

1.  Ventilation.- — Every  room  in  which  casting,  pasting  or  lead 
burning  is  carried  on  shall  contain  at  least  500  cubic  feet  of  air  space 


HEALTH  HAZARDS  IN  OCCUPATIONS  261 

for  each  person  employed  therein,  and  in  computing  this  air  space, 
no  height  above  14  feet  shall  be  taken  into  account. 

These  rooms  and  that  in  which  the  plates  are  formed  shall  be  capable 
of  thorough  ventilation.  They  shall  be  provided  with  windows  made 
to  open. 

2.  Separation  of  Processes. — Each  of  the  following  processes 
shall  be  carried  on  in  such  manner  and  under  such  conditions  as 
to  secure  effectual  separation  from  one  another  and  from  any  other 
process. 

(a)  Manipulation  of  dry  compounds  of  lead. 
(&)  Pasting. 

(c)  Formation  and  lead  burning  necessarily  carried  on  therewith. 

(d)  Melting  down  of  old  plates. 

Provided  that  manipulation  of  dry  compounds  of  lead  carried  on 
as  in  Regulation  5  (6)  need  not  be  separated  from  pasting. 

3.  Ploors. — The  floors  of  the  rooms  in  which  manipulation  of 
dry  compounds  of  lead  or  pasting  is  carried  on  shall  be  of  cement, 
or  similar  impervious  material,  and  shall  be  kept  constantly  moist 
while  work  is  being  done. 

The  floors  of  these  rooms  shall  be  washed  with  a  hose  pipe  daily. 

4.  Meeting  Pots. — Every  melting  pot  shall  be  covered  with  a 
hood  and  shaft  so  arranged  as  to  remove  the  fumes  and  hot  air  from 
the  workrooms. 

Lead  ashes  and  old  plates  shall  be  kept  in  receptacles  especially 
provided  for  the  purpose. 

5.  Manipulation  of  Dry  Compounds  of  Lead. — Manipulation  of 
dry  compounds  of  lead  in  the  mixing  of  the  paste  or  other  processes 
shall  not  be  done  except  (a)  in  an  apparatus  so  closed,  or  so  arranged 
with  an  exhaust  draught,  as  to  prevent  the  escape  of  dust  into  the 
workroom;  or  (b)  at  a  bench  provided  with  (1)  efficient  exhaust  draught, 
and  air  guides  so  arranged  ,as  to  draw  the  dust  away  from  the  worker, 
and  (2)  a  grating  on  which  each  receptacle  of  the  compound  of  lead 
in  use  at  the  time  shall  stand. 

6.  Covering  the  Benches. — The  benches  at  which  pasting  is  done 
shall  be  covered  with  sheet  lead  or  other  impervious  material,  and 
shall  have  raised  edges. 

7.  Prohibition  of  Emplojrment. — No  woman,  young  person,  or 
child  shall  be  employed  in  the  manipulation  of  dry  compounds  of 
lead  or  in  pasting. 

8.  (a)  Appointed  Surgeon. — A  duly  qualified  medical  practitioner 
(in  these  Regulations  referred  to  as  the  "Appointed  Surgeon")  who 
may  be  the  certifying  surgeon,  shall  be  appointed  by  the  occupier, 
such  appointment  unless  held  by  the  Certifying  Surgeon  to  be  subject 
to  the  approval  of  the  Chief  Inspector  of  Factories. 


262  INDUSTRIAL   MEDICINE    AND    SURGERY 

(h)  Medical  Examination. — Every  person  employed  in  a  lead 
process  shall  be  examined  once  a  month  by  the  Appointed  Surgeon, 
who  shall  have  power  to  suspend  from  employment  in  any  lead 
process. 

(c)  No  person  after  such  suspension  shall  be  employed  in  a  lead 
process  without  written  sanction  entered  in  the  Health  Register  by 
the  Appointed  Surgeon.  It  shall  be  sufficient  compliance  with  this 
regulation  for  a  written  certificate  to  be  given  by  the  Appointed  Sur- 
geon and  attached  to  the  Health  Register,  such  certificate  to  be 
replaced  by  a  proper  entry  in  the  Health  Register  at  the  Appointed 
Surgeon's  next  visit. 

(d)  Health  Register. — A  Health  Register  in  a  form  approved  by 
the  Chief  Inspector  of  Factories  shall  be  kept,  and  shall  contain  a 
list  of  all  persons  employed  in  lead  processes.  The  Appointed 
Surgeon  will  enter  into  the  Health  Register  the  dates  and  results  of 
his  examinations  of  the  persons  employed  and  particulars  of  any  direc- 
tions given  by  him.  He  shall  on  a  prescribed  form  furnish  to  the 
Chief  Inspector  of  Factories  on  the  first  day  of  January  in  each  year 
a  list  of  the  persons  suspended  by  him  during  the  previous  year,  the 
cause  and  duration  of  such  suspension,  and  the  number  of  exami- 
nations  made. 

The  Health  Register  shall  be  produced  at  any  time  when  required 
by  H.  M.  Inspectors  of  Factories  or  by  the  Certifying  Surgeon  or  by 
the  appointed  Surgeon. 

9.  Overalls. — Overalls  shall  be  provided  for  all  persons  employed 
in  manipulating  dry  compounds  of  lead  or  in  pasting.  The  overalls 
shall  be  washed  or  renewed  once  every  week. 

10.  Cloak  and  Dining  Rooms. — The  occupier  shall  provide  and 
maintain : 

{a)  A  cloak  room  in  which  workers  can  deposit  clothing  put  off 
during  working  hours.  Separate  and  suitable  arrangements  shall 
be  made  for  the  storage  of  overalls  required  in  Regulation  9. 

(h)  A  dining  room  unless  the  factory  is  closed  during  meal  hours. 

11.  Food,  Etc.^ — ^No  person  shall  be  allowed  to  introduce,  keep, 
prepare  or  partake  of  any  food,  drink,  or  tobacco,  in  any  room  in  which 
a  lead  process  is  carried  on.  Suitable  provision  shall  be  made  for  the 
deposit  of  food  brought  by  the  workers. 

This  regulation  shall  not  apply  to  any  sanitary  drink  provided  by 
the  occupier  and  approved  by  the  Appointed  Surgeon. 

12.  Washing. — The  occupier  shall  provide  and  maintain  for  the 
use  of  the  persons  employed  in  lead  processes  a  lavatory,  with  soap, 
nail  brushes,  towels,  and  at  least  one  lavatory  basin  for  every  five 
such  persons.  Each  such  basin  shall  be  provided  with  a  waste  pipe, 
or  the  basins  shall  be  placed  on  a  trough  fitted  with  a  waste  pipe. 


HEALTH  HAZARDS  IN  OCCUPATIONS  263 

There  shall  be  a  constant  supply  of  hot  and  cold  water  laid  on  each 
basin. 

Or,  in  the  place  of  basins  the  occupier  shall  provide  and  maintain 
troughs  of  enamel  or  similar  smooth  impervious  material,  in  g<K>d 
repair,  of  a  total  length  of  two  feet  for  every  five  persons  employed, 
fitted  with  waste  pipes,  and  without  plugs,  with  a  sufficient  supply 
of  warm  water  constantly  available. 

The  lavatory  shall  be  kept  thoroughly  cleansed  and  shall  be  sup- 
plied with  a  sufficient  quantity  of  clean  towels  once  every  day. 

13.  Before  each  meal  and  before  the  end  of  the  day's  work,  at 
least  ten  minutes,  in  addition  to  the  regular  meal  times,  shall  be  allowed 
for  washing  to  each  person  who  has  been  employed  in  the  manipula- 
tion of  dry  compounds  of  lead  or  in  pasting. 

Provided  that  if  the  lavatory  accommodation  specially  reserved 
for  such  person  exceeds  that  required  by  Regulation  12,  the  time 
allowance  may  be  proportionately  reduced,  and  that  if  there  be  one 
basin  or  two  feet  of  trough  for  each  such  person  this  regulation  shall 
not  apply. 

14.  Baths. — Sufficient  bath  accommodation  shall  be  provided  for 
all  persons  engaged  in  the  manipulation  of  dry  compounds  of  lead  or 
in  pasting,  with  hot  and  cold  water  laid  on,  and  a  sufficient  supply  of 
soap  and  towels. 

This  rule  shall  not  apply  if  in  consideration  of  the  special  cir- 
cumstances of  any  particular  case,  the  Chief  Inspector  of  Factories 
approves  the  use  of  local  public  baths  when  conveniently  near,  under 
the  conditions  (if  any)  named  in  such  approval. 

15.  Cleaning. — The  floors  and  benches  of  each  workroom  shall 
be  thoroughly  cleansed  daily,  at  a  time  when  no  other  work  is  being 
carried  on  in  theroom. 

Duties  of  Persons  Employed 

16.  Medical  Examination.^ — All  persons  employed  in  lead  processes 
shall  present  themselves  at  the  appointed  times  for  examination  by  the 
appointed  surgeon  as  provided  in  regulation  8. 

No  person  after  suspension  shall  work  in  a  lead  process,  in  any 
factory  or  workshop  in  which  electric  accumulators  are  manufactured, 
without  written  sanction  entered  in  the  health  register  by  the  appointed 
surgeon. 

17.  Overalls. — Every  person  employed  in  the  manipulation  of  dry 
compounds  of  lead  or  in  pasting  shall  wear  the  overalls  provided  under 
Regulation  9.  The  overalls,  when  not  being  worn,  and  clothing  put 
off  during  working  hours,  shall  be  deposited  in  the  places  under 
Regulation  10. 

18.  Food,    Etc. — No   person    shall   introduce,    keep,    prepare,   or 


264  INDUSTRIAL    MEDICINE    AND    SURGERY 

partake  of  any  food,  drink  (other  than  any  sanitary  drink  provided 
by  the  occupier  and  approved  by  the  appointed  surgeon),  or  tobacco 
in  any  room  in  which  a  lead  process  is  carried  on. 

19.  Washing. — No  person  employed  in  a  lead  process  shall  leave 
the  premises  or  partake  of  meals  without  previously  and  carefully 
cleaning  and  washing  the  hands. 

20.  Baths. — Every  person  employed  in  the  manipulation  of  dry 
compounds  of  lead  or  in  pasting  shall  take  a  bath  at  least  once  a  week. 

21.  Interference  with  Safety  Appliances. — No  person  shall  in  any 
way  interfere,  without  the  concurrence  of  the  occupier  or  manager, 
with  the  means  and  appliances  provided  for  the  removal  of  the  dust 
or  fumes,  and  for  the  carrying  out  of  these  regulations. 

The  Massachusetts  State  Board  of  Health  has  issued  the  following 
protective  measures  in  a  publicity  campaign  against  lead  poisoning: 
"The  poison  gains  entrance  into  the  system: 

(1)  By  swallowing  minute  particles  of  lead. 

(2)  By  inhaling  lead  dust  or  fumes  of  lead  in  a  molten  state 
or  the  vapor  of  lead  in  a  fused  state. 

(3)  By  absorption  from  the  skin  in  handling  lead. 

Advice  to  Employees 

1.  General  personal  cleanliness  is  of  first  importance. 

2.  Thoroughly  clean  your  hands  before  touching  food  or  before 
leaving  the  workroom. 

3.  Thoroughly  rinse  your  mouth  before  eating. 

4.  Take  a  substantial  breakfast;  an  empty  stomach  is  more  sus- 
ceptible to  the  poisonous  effects  of  lead. 

5.  Take  good  nutritious  food  and  plenty  of  milk. 

6.  Never  eat  at  your  work.  Eat  your  luncheon  outside  of  the 
workroom  away  from  the  lead.  Never  smoke  or  use  tobacco  in  any 
form  while  at  work. 

7.  Avoid  all  excesses!     Alcoholic  beverages  are  especially  injurious. 

8.  Wear  overalls  or  a  long  coat  at  your  work;  also  a  cap  or  some 
head  covering.  Wherever  practical  wear  gloves  when  lead  is  to  be 
handled. 

9.  Persons  working  in  white  lead  or  other  powdered  compounds  of 
lead  should  always  wear  respirators  while  at  work.  Cause  as  little 
dust  as  possible. 

10.  Consult  a  physician  at  the  first  sign  of  ill  health. 

Advice  to  Employers 

1.  Provide  washing  facilities,  lockers,  and  a  place  for  the  employees 
to  eat  luncheons  away  from  lead. 


HEALTH  HAZARDS  IN  OCCUPATIONS  265 

2.  Provide  respirators  for  all  workers  who  have  to  handle  white 
lead  or  other  powdered  compounds  of  lead. 

3.  The  floors  of  the  workrooms  and  the  benches  at  which  men  work 
should  be  cleaned  daily  after  thoroughly  moistening  them. 

4.  These  regulations  should  be  posted  in  a  conspicuous  place  in 
the  workrooms." 

White  Lead.- — ^The  processes  in  the  production  of  white  lead  which 
create  dust  are  the  most  dangerous.  Chambers  should  only  be  emptied 
by  men  wearing  respirators.  Vacuum  cleaning  apparatus  should  be 
used  to  clean  all  dusty  apparatus.  Drying  stoves  should  as  far  as 
possible  be  mechanically  charged.  Similar  measures  should  be  em- 
ployed in  the  production  of  red  lead,  and  lead  chromates. 

The  Painters  Trade. — The  painters  trade  in  all  countries  furnishes 
employment  for  a  larger  number  of  men  than  any  other  lead  trade. 
Because  the  men  do  not  always  work  in  shops  but,  as  in  the  case  of 
house  painters,  in  the  various  places  where  painting  must  be 
done  it  is  an  especially  difficult  trade  in  which  to  control  the  working 
conditions. 

The  workers  themselves  sometimes  recognize  some  of  the  dangers 
to  which  they  are  exposed  as  is  evidenced  by  the  following  reason- 
able demands  made  by  the  Brotherhood  of  Chicago  Painters  and 
paperhangers  during  a  strike  in  April,  1913: 

''  No  workmen  or  apprentices  shall  be  required  to  use  any  poisonous 
substance  or  material  injurious  to  health,  such  as  wood  alcohol, 
varnish  remover,  oxalic  acid,  or  the  sanding  of  lead,  etc.,  unless  they 
are  protected  with  respirators,  gloves,  etc.,  same  to  be  furnished  by 
the  employer;  nor  shall  they  be  required  to  use  any  dirty  or  insanitary 
waste,  rags  or  drop  cloths.  There  shall  be  an  allowance  of  five 
minutes  for  wash  time  in  each  four  hours'  work,  and  where  lead  or 
other  poisonous  material  is  used,  the  employer  shall  furnish  hot  water, 
soap  and  towels  to  the  workmen.  The  officers  and  members  of  the 
organization    shall    enforce    this    clause." 

The  German  regulations,  as  quoted  by  Rambousek,  covering  the 
trades  of  this  group  are  admirable: 

I.  Regulations  for  carrying  on  the  Industries  of  Painting,  Distem- 
pering, Whitewashing,  Plastering  or  Varnishing. 

Regulation — 1.  In  the  processes  of  crushing,  blending,  mixing 
and  otherwise  preparing  white  lead,  other  lead  colors,  or  mixtures 
thereof  with  other  substances  in  a  dry  state,  the  workers  shall  not 
directly  handle  pigment  containing  lead,  and  shall  be  adequately 
protected    against   the    dust    arising   therefrom. 

Regulation  2. — The  process  of  grinding  white  lead  with  oil  or 
varnish  shall  not  be  done  by  hand,  but  entirely  by  mechanical  means, 
and  in  vessels  so  constructed  that  even  in  the  processes  of  charging 


266  INDUSTRIAL    MEDICINE    AND    SURGERY 

them  with  white  lead  no  dust  shall  escape  into  places  where  work  is 
carried  on. 

This  provision  shall  apply  to  other  lead  colors.  Provided  that 
such  lead  colors  may  be  ground  by  hand  by  male  workers  over 
eighteen  years  of  age,  if  not  more  than  one  kilogram  of  red  lead  and 
one  hundred  grains  of  other  lead  colors  are  ground  by  any  one  worker 
in   one    day. 

Regulation  3. — The  processes  of  rubbing  down  and  pumice- 
stoning  dry  coats  of  oil  color  or  stopping,  not  clearly  free  from  lead, 
shall  not  be  done  except  after  damping. 

All  debris  produced  by  rubbing  down  and  pumice-stoning  shall 
be  removed   before   it  becomes  dry. 

Regulation  4:. — The  employer  shall  see  that  every  worker  who 
handles  lead  colors  or  mixtures  thereof  is  provided  with,  and  wears, 
during  working  hours,  a  painter's  overall  or  other  complete  suit  of 
working  clothes. 

Regulation  5.' — There  shall  be  provided  for  all  workers  engaged 
in  processes  of  painting,  distempering,  whitewashing,  plastering,  or 
varnishing,  in  which  lead  colors  are  used,  washing  utensils,  nail 
brushes,  soap  and  towels.  If  such  processes  are  carried  on  in  a  new 
building  or  in  a  workshop,  provision  shall  be  made  for  the  workers  to 
wash  in  a  place  protected  from  frost,  and  to  store  their  clothing  in 
a  clean  place. 

Regulation  6. — The  employer  shall  inform  workers,  who  handle 
lead  colors  or  mixtures  thereof,  of  the  danger  to  health  to  which  they 
are  exposed,  and  shall  hand  them,  at  the  commencement  of  employ- 
ment, a  copy  of  the  accompanying  leaflet  (not  printed  with  this 
edition),  if  they  are  not  already  provided  with  it,  and  also  a  copy 
of  these  regulations. 

II.  Regulations  for  the  Processes  of  Painting,  Distempering, 
Whitewashing,  Plastering,  or  Varnishing  when  carried  on  in  con- 
nection with  another  Industry. 

Regulation  7.- — The  provisions  of  paragraph  6  shall  apply  to  the 
employment  of  workers  connected  with  another  industry  who  are 
constantly  or  principally  employed  in  the  processes  of  painting,  dis- 
tempering, whitewashing,  plastering,  or  varnishing,  and  who  use, 
otherwise  than  occasionally,  lead  colors  or  mixtures  thereof.  The 
provisions  of  paragraphs  8  to  11  shall  also  apply  if  such  employment 
is  carried  on  in  a  factory  or  shipbuilding  yard. 

Regulation  8. — Special  accommodation  for  washing  and  for  dressing 
shall  be  provided  for  the  workers,  which  accommodation  shall  be  kept 
clean,  heated  in  cold  weather,  and  furnished  with  conveniences  for 
the  storage  of  clothing. 

Regulation  9. — The  employer  shall  issue  regulations  which  shall  be 


HEALTH  HAZARDS  IN  OCCUPATIONS  267 

binding  on  the  workers,  and  shall  contain  the  following  provisions 
for  such  workers  as  handle  lead  colors  and  mixtures  thereof : 

1.  Workers  shall  not  consume  spirits  in  any  place  where  work 
is  carried  on. 

2.  Workers  shall  not  partake  of  food  or  drink,  or  leave  the  place 
of  employment  until  they  have  put  off  their  working  clothes  and 
carefully  washed  their  hands. 

3.  Workers  when  engaged  in  processes  specified  by  the  employer, 
shall  wear  working  clothes. 

4.  Smoking  cigars  and  cigarettes  is  prohibited  during  work. 
Furthermore  it  shall  be  set  forth  in  the  regulations  that  workers 

who,  in  spite  of  reiterated  warning,  contravene  the  foregoing  provi- 
sions may  be  dismissed  before  the  expiration  of  their  contract  without 
notice. 

If  a  code  of  regulations  has  been  issued  for  the  industry  above 
indicated,  provisions  shall  be  incorporated  in  the  said  code. 

Regulation  10.' — The  employer  shall  entrust  the  supervision  of  the 
worker's  health  to  a  duly  qualified  medical  man  approved  of  by  the 
public  authority,  and  notified  to  the  factory  inspector,  and  the  said 
medical  man  shall  examine  the  workers  once  at  least  in  every  six 
months  for  symptoms  indicative  of  plumbism. 

The  employer  shall  not  permit  any  worker  who  is  suffering  from 
plumbism  or  who,  in  the  opinion  of  the  doctor,  is  suspected  of  plum- 
bism, to  be  employed  in  any  work  in  which  he  has  to  handle  lead 
colors  or  mixtures  thereof,  until  he  has  completely  recovered. 

Regulation  11. — The  employer  shall  keep  or  cause  to  be  kept  a 
register  in  which  shall  be  recorded  the  state  of  health  of  the  workers, 
and  also  the  constitution  of  and  changes  in  the  staff;  and  he  shall  be 
responsible  for  the  entries  being  complete  and  accurate,  except  in  so 
far  as  they  are  affected  by  the  medical  man. 

The  Printing  Trades. — It  is  undesirable  that  open  metal  pots  should 
be  in  a  general  room  where  type-casting  and  setting  and  machinery  are 
at  work.  The  pots  should  be  hooded  and  the  fumes  carried  away 
by  exhaust  ventilation.  It  is  important  that  these  fumes  shall  not 
be  distributed  too  near  factories  or  dwelling  places.  In  cleaning 
the  flues  men  should  be  equipped  with  breathing  apparatus.  Local 
exhaust  ventilation  should  be  applied  to  type  cases  and  letter  casting 
machines.  Vacuum  cleaning  of  workrooms  and  type  cases  is  strongly 
advised.  Several  hygienic  safeguards  against  plumbism  are  of  course 
necessary. 

The  Ceramic  Industries. — In  May,  1898,  in  England,  the  Home 
Secretary  appointed  Professor  Thorpe  and  Dr.  Thomas  Oliver  to  make 
special  inquiry  and  ascertain  (1)  how  far  the  danger  (of  lead  poison- 
ing in  potteries)   may   be   diminished  or  removed  by  substituting 


268  INDUSTRIAL   MEDICINE    AND    SURGERY 

for  the  carbonate  of  lead  ordinarily  used,  either  (o)  one  or  other  less 
soluble  compound  of  lead,  e.g.,  a  silicate;  (6)  leadless  glaze;  (2)  how 
far  any  substitutes  found  to  be  harmless  or  less  dangerous  than  the 
carbonate  of  lead  fit  themselves  to  the  varied  practical  requirements 
of  the  manufacturer;  (3)  what  other  preventive  measures  can  be 
adopted.  ♦" 

The  recommendations  of  this  committee  were: 

"1.  That  by  far  the  greater  amount  of  earthenware  of  the  class 
already  specified,  i.e.,  the  white  and  cream  colored  ware,  can  be  glazed 
without  the  use  of  lead  in  any  form.  It  has  been  demonstrated  with- 
out the  slighest  doubt  that  the  ware  so  made  is  in  no  respect  inferior 
to  that  coated  with  lead  glaze.  There  seems  no  reason,  therefore,  why 
in  the  manufacture  of  this  class  of  goods  the  operatives  should  still 
continue  to  be  exposed  to  the  evils  which  the  use  of  lead  entails. 

2.  There  are,  however,  certain  branches  of  the  pottery  industry 
in  which  it  would  be  more  difficult  to  dispense  with  the  use  fef  lead 
compounds.  But  there  is  no  reason  why,  in  these  cases,  the  lead  so 
employed  should  not  be  in  the  form  of  a  fritted  double  silicate.  Such 
a  compound,  if  properly  made,  is  but  slightly  attacked  by  even  strong 
hydrochloric,  acetic,  or  lactic  acid.  There  is  little  doubt  that  if  lead 
must  be  used,  the  employment  of  such  a  compound  silicate — if  its 
use  could  be  insured — would  greatly  diminish  the  evil  of  lead  poisoning. 

3.  The  use  of  raw  lead  as  an  ingredient  of  glazing  material,  or  as 
an  ingredient  of  colors  which  have  to  be  subsequently  fired,  should  be 
absolutely  prohibited. 

4.  As  it  would  be  very  difficult  to  insure  that  an  innocuous  lead 
glaze  shall  be  employed,  we  are  of  the  opinion  that  young  persons  and 
women  should  be  excluded  from  employment  as  dippers,  dippers' 
assistants,  ware  cleaners  after  dippers,  and  glost  placers  in  factories 
where  lead  glaze  is  used,  and  that  the  adult  male  dippers,  dippers' 
assistants,  ware  cleaners,  and  glost  placers  should  be  subjected  to 
systematic  medical  inspection." 

The  danger  of  plumbism  is  greatest  in  small  works  since  the  technic 
necessary  for  the  production  of  leadless  glazes  make  their  production 
in  small  quantities  difficult  and  discontinuance  of  the  use  of  lea  glazes 
necessitates  the  complete  alteration  of  their  equipment  for  manufac- 
ture. Furthermore  the  cost  of  installation  of  localized  exhaust  ventila- 
tion is  far  greater  in  proportion  to  the  cost  of  production  in  the  small 
than  in  the  large  factory.  Teleky,  Chyzer  and  the  Dutch  Inspector 
DeVooys,^  have  demanded  the  total  prohibition  of  the  use  of  lead 
glazes  and  in  Bohemia,  at  the  cost  of  the  state,  technical  instruction 
has  been  given  in  the  preparation  of  leadless  glazes  in  the  districts 
where  the  ceramic  industries  are  carried  on  in  the  homes  of  the  workers. 
iRambousek;   "industrial  Poisoning,"  p.  320. 


HEALTH  HAZARDS  IN  OCCUPATIONS  269 

Rambousek,  contrary  to  Oliver,  does  not  expect  much  good  from  the 
obligatory  use  of  fritted  glazes. 

In  Great  Britain  the  china  and  earthenware  industry  is  placed  under 
Regulations  dated  January  2,  1913,  which  supersede  the  previous 
Special  Rules.  These  Regulations- — thirty-six  in  number — provide, 
among  other  usual  provisions,  (1)  for  efficient  exhaust  ventilation  in 
(a)  processes  giving  rise  to  injurious  mineral  dust  (settling  and  pressing 
of  tiles,  bedding,  and  flinting,  brushing  and  scouring  of  biscuit)  and  (h) 
dusty  lead  processes  (ware  cleaning,  aerographing,  color  dusting, 
litho-transfer  making,  etc.);  and  (2)  monthly  periodical  medical  ex- 
amination of  workers  in  scheduled  processes. 

Zinc,  Brass-casting,  Metal  Pickling,  Galvanizing. — Metallic  fumes 
from  zinc  smelting  contain  lead,  zinc,  arsenic,  sulphur  dioxid  and 
carbon  dioxid.  These  require  to  be  condensed  in  a  specially  arranged 
system.  Hoods  should  be  arranged  over  the  fronts  of  furnaces  so 
that  fumes  arising  during  the  removal  of  distillation  residues  can  be 
conducted  into  the  chimney  stock  or  drawn  away  by  a  fan.  The 
residue  should  be  automatically  removed  from  the  furnaces  into 
closed  receptacles  where  it  is  confined  until  cooled.  The  mixing 
of  materials  for  charging  as  well  as  the  sifting  and  packing  of  the  zinc 
dust  should  be  done  mechanically  under  local  exhaust  ventilation. 
The  regulations  to  control  zinc  smelting  should  be  practically  the  same 
as  those  of  lead. 

In  brass-casting  the  development  of  brass  founders'  ague  is  best 
prevented  by  the  local  exhaustion  of  zinc  oxid  fumes  as  they  escape 
from  the  crucible.  Casting  is  often  done  in  various  places  throughout 
the  foundry  and  it  is  necessary  to  install  small  hoods  connected  to  the 
exhaust  ventilation  system  by  flexible  hose  which  can  be  moved  about 
to  cover  any  region  where  the  casting  may  be  in  operation  to  protect 
the  face  of  the  pourer. 

In  metal  pickling  dangerous  acid  fumes  are  evolved  and  require 
that  the  work  be  done  in  isolated  chambers  with  exhaust  ventilation. 
Well  adapted  for  this  purpose  is  a  wooden  compartment  closed  in 
except  for  a  small  opening  in  front  exhausted  by  an  acid  proof  stone- 
ware fan  which  leads  the  fumes  through  a  stoneware  pipe  to  an  ab- 
sorption tower  through  which  water  trickles.  The  water  thus  charged 
with  acid  can  often  be  utilized. 

In  galvanizing  and  tinning  processes  acroleic  vapors  and  metallic 
fumes  arise  as  the  metal  objects  are  cleansed  and  dipped.  These 
fumes  must  be  exhausted  as  described  above. 

Mercury. — In  smelting  cinnabar  sulphur  dioxid  and  mercury 
fumes  must  both  be  exhausted.  The  mercury  deposit  in  the  flues 
should  only  be  removed  after  watering  and  by  workers  provided  with 
breathing  apparatus  and  working  suits. 


270  INDUSTRIAL    MEDICINE    AND    SURGERY 

The  advisability  of  the  substitution  of  other  chemicals  for  mer- 
cury in  mirror  making  has  been  mentioned  before. 

In  using  nitrate  of  mercury  in  the  manufacture  of  felt  hats,  dust 
and  nitric  fumes  must  be  exhausted  and  strict  personal  hygiene  of 
the  workers  insisted  upon.  In  France  the  following  notice  is  required 
to  be  posted  in  animal  hair  cutting  establishments  where  mercury 
is  used: 

"Mercury  and  its  compounds  are  dangerous.  They  may  enter  the 
body  with  the  air  breathed  in  (dust,  vapors),  with  the  food  (unclean 
hands,  unclean  tables),  through  the  skin  (cracks,  scratches  or  cuts). 

Should  you  have  any  cracks,  scratches  or  cuts,  please  inform  the 
management  immediately  of  the  fact. 

Before  eating  or  drinking  carefully  clean  your  hands  with  soap 
and  your  mouth  with  drinking  water. 

Should  you  have  any  pains  in  the  mouth  or  teeth  and  excessive 
quantity  of  saliva,  should  you  shiver,  should  you  have  swelling  of 
the  legs,  hands  or  under  the  eyes,  consult  the  doctor  at  once." 

Air  pumps  should  be  substituted  for  mercury  pumps  in  produc- 
ing the  vacuum  in  electric  light  bulbs.  Careless  handling  of  this 
volatile  metal  will  endanger  dentists,  barometer  and  thermometer 
makers. 

In  chemical  factories  calomel  and  corrosive  sublimate,  and  the 
other  mercury  salts  should  be  ground  and  prepared  in  closed  appa- 
ratus. The  following  are  general  preventive  measures  for  workers 
in  mercury  suggested  by  Dr.  George  M.  Kober: 

1.  The  imperative  necessity  of  providing  local  exhaust  ventila- 
tion wherever  dust  and  fumes  are  evolved,  as  well  as  a  reduction 
of  working  hours  during  the  warm  weather,  should  be  generally 
recognized. 

2.  All  processes  involving  the  use  of  mercury  should  be  carried 
on  in  separate  rooms,  with  a  northern  exposure  of  the  windows,  pref- 
erably at  a  temperature  below  60°,  so  as  to  reduce  the  danger  from 
volatilization  of  the  metal  to  a  minimum.  Work  should  be  suspended 
when  the  temperature  exceeds  78°. 

3.  Wooden  floors  and  work  benches  are  objectionable  as  they 
favor  the  lodgment  of  spilled  mercury  in  cracks  and  crevices.  Ena- 
meled iron  benches  and  smooth  asphalt  floors,  provided  with  an  in- 
cline and  channels  toward  receptacles  in  which  the  mercury  may  collect 
should  be  chosen.  The  receptacles  should  be  covered  leaving  only 
a  narrow  opening    just  sufficient  for  the  metal  to  enter. 

4.  Absolute  care  to  prevent  spilling  of  the  mercury  should  be 
exercised.  The  work  benches  should  be  freed  from  the  metal  upon 
cessation  of  work,  the  floors  should  be  sprinkled  and  swept  two  or 
three  times  a  day. 


HEALTH  HAZARDS  IN  OCCUPATIONS  271 

5.  The  workers  should  be  supphed  with  respirators  in  all  dust 
producing  processes;  overalls  and  a  suitable  head  covering  of  a  per- 
fectly smooth  material  should  be  used  and  washed  weekly.  The 
hair  should  be  worn  closely  trimmed,  preferably  no  beard;  female 
and  youthful  employees  should  be  excluded.  The  use  of  alcoholic 
beverages  and  tobacco  should  be  prohibited. 

6.  Cleanliness  of  person  and  clothing  are  of  the  utmost  importance. 
No  food  should  be  taken  in  the  workrooms  and  in  no  case  until  after 
thorough  washing  of  the  face  and  hands  with  soap  and  water,  using 
a  brush  for  the  finger  nails,  also  washing  the  mouth  and  teeth  with 
brush  and  water,  followed  by  the  use  of  a  mouth  wash  and  gargle  with 
a  solution  of  either  chlorate  or  permanganate  of  potash  or  phenate 
of  sodium.  Heucke  recommends  the  use  of  akremin  soap,  containing 
soluble  alkaline  sulphides,  and  believes  that  the  wash  water  should 
also  contain  potassium  sulphuratum  so  as  to  convert  the  mercury  into 
insoluble  sulphides. 

7.  The  firm  should  provide  not  only  all  the  necessities  referred 
to  but  also  the  facilities  for  warm  shower  and  tub  baths,  suitable 
lockers  for  clothing,  lunch  rooms,  and  periodical  medical  examina- 
tion of  the  employees,  with  suspension  from  work  if  any  are  found  to 
present  symptoms  of  mercurial  poisoning. 

Arsenic  and  Arseniuretted  Hydrogen.^ — Since  arsenic  is  a  power- 
ful poison  it  is  very  important  that  the  greatest  possible  care  should 
be  taken  by  all  who  are  engaged  in  its  manufacture  or  brought 
in  contact  with  it.  Dr.  George  M.  Kober  suggests  the  following 
regulations : 

The  officials  and  workmen  are  requested  to  strictly  observe  the 
following  rules,  and  generally  to  take  every  precaution  to  prevent 
arsenical  poisoning: 

1.  In  the  process  of  de-arsenicating  Vitriol,  care  must  be  taken 
to  maintain  an  in-draught  in  the  pipes  and  apparatus,  to  prevent 
escape  of  arsenical  fumes,  and  should  an  escape  be  observed,  the  brine 
(or  hydrochloric  acid)  should  be  at  once  shut  off  until  the  effect  is 
remedied. 

2.  In  the  precipitating,  drying  and  packing  operations,  a  clean 
respirator  (Grell's  improved  pattern)  must  always  be  used.  A  clean 
one  must  be  obtained  every  morning  from  the  laboratory,  and  the  one 
used  the  previous  day  returned  to  the  laboratory  to  be  cleansed  and 
prepared  for  use  the  next  day. 

3.  Every  workman  engaged  in  this  process  shall  be  provided  by  the 
company  with  a  pair  of  India  rubber  gloves  and  a  suit  of  clothes,  which 
he  is  to  put  on  in  the  morning  and  remove  on  leaving  the  works  at 
night,  and  shall  take  a  bath  before  putting  on  his  ordinary  clothing. 
These  special  clothes  to  be  washed  by  the  company  and  supplied 


272  INDUSTRIAL    MEDICINE    AND    SURGERY 

clean  to  the  workman  once  a  week.     Workmen  must  thoroughly  wash 
their  hands  before  taking  food  in  the  works. 

4.  The  buildings  in  which  the  manufacture  of  arsenic  is  carried  on 
must  be  well  ventilated  to  remove  all  fmnes  of  chlorid  of  arsenic  or 
dust  of  arsenious  acid  from  the  atmosphere. 

5.  Any  workman  having  cuts  or  abrasions  on  the  skin  will  not  be 
permitted  to  work  in  the  arsenical  department  until  such  wounds 
have  quite  healed. 

6.  Any  workman  showing  the  slightest  signs  of  arsenical  poisoning 
must  be  examined  by  a  doctor  and  undergo  medical  treatment. 

Respirators  should  be  worn  by  those  handling  white  arsenic  and 
packing  or  dusty  processes  should  be  done  under  local  exhaust  ventila- 
tion. In  arsenic  work  imperviousness  of  the  system  is  imperative. 
In  technical  processes  and  the  trades,  substitutes  should  replace 
arsenic  wherever  possible. 

All  workmen  in  such  industries  as  may  necessitate  even  the  pos- 
sibility of  exposure  to  arseniuretted  hydrogen  gas  such  as  in  soldering 
with  hydrogen,  in  galvanizing  processes,  in  extracting  metals  with 
acids,  and  in  storage  battery  manufacture,  should  be  made  thoroughly 
conversant  with  the  danger  and  instructed  in  the  use  of  first  aid 
methods  in  the  case  of  emergency. 

Gold  and  Silver. — The  same  precautions  apply  to  the  extraction 
of  the  precious  metals  by  amalgamation  with  mercury  and  volatiliza- 
tion as  are  mentioned  under  the  use  of  mercury. 

Varnishes  and  Drying  Oils.- — Closely  fitting  covers  should  be 
applied  when  linseed  oil  is  boiled  with  oxidizing  substances  or  in 
dissolving  resin  and  the  fumes  should  be  condensed  in  cooling  apparatus. 

Especial  care  should  be  exercised  in  the  use  of  quick  drying  paints 
in  the  interior  of  rooms  or  ships  or  inside  steam  boilers,  or  any  other 
enclosed  place  as  fatalities  have  occurred  from  the  inhalation  of  such 
poisonous  solvents  as  benzin  and  turpentine. 

COMPENSATION  AND  INSURANCE 

The  third  class  of  preventive  measures  against  diseases  of  oc- 
cupation is  that  of  compensation  and  insurance. 

The  principal  question  involved  in  the  establishment  of  a  method  of 
compensation  or  insurance  is  that  of  ascertaining  the  per  cent,  to  be 
borne  by  the  community  or  state  and  the  per  cent,  to  be  borne  by  the 
employer.  Whether,  as  the  supreme  courts  of  some  of  the  states 
such  as  California  and  Massachusetts  have  recently  held,  lead  poisoning 
and  other  occupational  intoxications  can  be  considered  as  "personal 
injuries"  or  not,  it  certainly  is  as  fair  that  compensation  should  be 
awarded  the  victim  of  occupational  disease  as  that  it  should  be  given 


HEALTH  HAZARDS  IN  OCCUPATIONS  273 

to  the  victim  of  an  industrial  accident.  If  the  employer  is 
required  to  bear  a  part  of  the  burden  of  providing  compensation 
for  the  employee  disabled  by  industrial  disease,  the  importance 
of  prevention  of  such  conditions  is  thereby  most  forcibly  impressed 
upon  him.  If,  however,  the  employer  has  done  all  that  he  can  to  make 
the  occupation  of  his  employees  conform  with  the  laws  in  effect  cover- 
ing such  occupations  and  follows  the  suggestions  made  by  the  agencies 
especially  trained  and  competent  in  the  prevention  of  these  conditions, 
there  is  no  moral  reason  why  he  should  pay  compensation  for  occupa- 
tional diseases.  The  state  in  allowing  hazardous  occupations  to 
exist  and  thus  acknowledging  that  the  products  of  such  occupations 
are  necessary  to  the  commonwealth  thereby  tacitly  admits  that  it 
is  responsibe  for  illness  specifically  due  to  such  occupation  and  should 
bear  the  burden  of  compensation. 

In  either  case  the  expense  of  compensation  would  prove  one  of  the 
greatest  incentives  for  adequate  prevention  of  occupational  diseases. 

18 


274 


INDUSTRIAL    MEDICINE    AND    SURGERY 


LIST  OF  INDUSTRIAL  POISONS 
(Translated  by  Wm.  H.  Rand,  M.  D.) 


(From  Bulletin  of  the  Bureau  of  Labor,  No.  100,  May,  1912) 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


ACETALDEHYD 
ETHYLALDEHYD, 
CH3COH:  A  color- 
less, very  volatile 
fluid,     of     pungent 

,  odor. 


Manufacture  of  vine- 
gar; silver  mirror 
manufacture. 


In  the  form 
of  vapor, 
through  the 
respiratory 
organs  and 
mucous  mem- 
branes. 


Irritation  of  the  mucous  membranes 
of  the  nose,  larynx,  and  bronchi; 
irritation  of  the  mucous  membrane 
of  the  eyes;  acceleration  of  the 
heart's  action;  profuse  night 
sweats. 


ACRIDIN,  C13H9N: 
Crystallizing  in  col- 
orless needles;  con- 
tained in  anthra- 
cene. 


ACROLEIN,  C2H3- 
COH:  A  colorless, 
very  pungent  smell- 
ing fluid,  of  fiery 
taste. 


AMMONIA,  NHs:  A 

colorless  gas  of 
sharply  penetrating 
odor. 


Organic    dyes    indus- 
try. 


In  the  trying  out  of 
fat  and  fat  con- 
taining material, 
e.g.,  in  bone  ren- 
dering plants ;  oil- 
cloth and  linoleum 
factories;  varnish- 
boiling  shops;  tal- 
low-rendering es- 
tablishments; soap 
factories  (sulphuric 
acid  process),  and 
stearic-acid  factories. 


Exerts  effect  in 
any  state  of 
aggregation 
on  skin  and 
mucous  mem- 
branes. 


Irritation  and  inflammation  of  skin 
and  mucous  membranes;  severe 
burning  and  itching  of  the  skin; 
violent  sneezing. 


In  vaporous 
form,  through 
the  organs  of 
respiration 
and  the  mu- 
cous mem- 
branes. 


Coke  ovens;  mirror- 
silvering  _  industry; 
coating  iron  plate 
with  tin  or  zinc; 
manufacture  of 
solidified  ammo- 
nia, sulphate  and 
chlorid  of  am- 
monium (sal  am- 
moniac) from  am- 
monia  water; 
manufacture  of  the 
carbonate  of  soda 
and  of  orselle  dye- 
stuffs;  dyeing  in- 
dustry; sewer 
cleaning;  manufac- 
ture of  bone  black; 
gas  plants ;  varnish 
and  lacquer  manu- 
facture; tanning; 
beet-sugar  m  a  n  u- 
facture;  _  manufac- 
ture of  ice;  refrig- 
eration plants. 


In  gaseous 

form,  through 
the  organs  of 
respiration. 
Seldom  pure, 
mostly  in 

combination 
with        other 


Immediate 
effect   on  the 
conjunctiva 
and   the   cor 
nea. 


Itching  in  the  throat;  irritation  of 
the  eyes,  exciting  lachrimation, 
conjunctivitis;  irritation  of  the  air 
passages,  bronchial  catarrh. 


A  proportion  of  more  than  0.15  per 
cent,  of  ammonia  in  the  air  imme- 
diately causes  an  irritable  con- 
dition of  the  mucous  membranes. 
Chronic  bronchial  catarrhs  are 
especially  liable  to  follow  long- 
continued  inhalation  of  small 
quantities  of  the  gas  diffused  in  the 
air.  From  these  are  to  be  dis- 
criminated the  acute  conditions  of 
transient  illness:  Intense  irrita- 
tion of  the  respiratory  organs; 
violent  sneezing;  lachrimation, 
redness  of  the  eyes,  inflammation 
of  the  cornea  and  of  the  conjunc- 
tiva; increased  secretion  of  saliva; 
burning  in  the  pharynx,  and  a 
sense  of  constriction  in  the  larynx; 
paroxysmal  cough,  with  secretion 
of  tenacious,  viscid,  even  bloody, 
mucus;  embarrassment  of  respira- 
tion, attacks  of  suffocation;  vomit- 
ing of  serous  masses;  ammoniacal 
odor  of  the  perspiration;  retention 
of  urine,  which  may  last  many 
hours  and  even  two  or  three  days; 
acute  inflammation  of  the  respira- 
tory organs,  and  scattered  areas  of 
inflammation  in  the  lungs,  in 
severe  cases,  a  fatal  outcome. 
Protracted  _  breathing  of  small 
quantities  is  apt  to  cause  chronic 
bronchial  catarrh. 


Special  measures  of  relief :  Immediate  removal  from  the  poisonous  atmosphere;  artificial  respira- 
tion; inhalation  of  steam;  faradic  stimulation  of  the  phrenic  nerve;  free  bloodletting;  in  case  of 
obstinate  spasm  of  the  glottis,  tracheotomy. 


HEALTH  HAZARDS  IN  OCCUPATIONS 


275 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


AMYL  ACETATE, 
C6HnCH3C02:  Za- 
pone,  a  solution  of 
celluloid  in  amyl 
acetate  and  acetone 


Zapone  lacquer  used 
as  a  lacquering 
agent  in  metallic 
ware  and  jewelry 
factories;  manu- 

facture of  metallic 
wire  for  incandes- 
cent electric  lamps; 
oilcloth  manufac- 
ture. 


In  the  form 
of  vapor, 
through  the 
respiratory 
organs. 


Nervous  symptoms;  headache;  full- 
ness of  the  head;  Kiddiness;  nausea; 
numbness;  flisturbanros  of  diges- 
tion; palpitations  of  the  heart. 


AMYL    ALCOHOL, 

CoHiiGH:  A  color- 
less, oily  fluid,  of 
very  sharp  taste 
and  penetrating, 
disagreeable  odor. 


Manufacture  of  fruit 
essences,  nitrite 

of  amyl,  valeric 
acid,  and  anilin 
dyes;  rectification 
of  spirits. 


In  the  form 
of  vapor, 
through  the 
organs  of  res- 
piration. 


Congestion  of  .the  head;  headache; 
oppression  of  the  chest;  irritation 
of  the  air  passages. 


ANILIN,  CrH.^(N- 
H2):  A  colorless  oil 
which  acquires  a 
tint  on  exposure  to 
air  and  light.  Like 
anilin,  all  other 
amid  compounds  of 
benzol  and  its  homo- 
logues,  as  toluol, 
naphthalin,  xylol, 
etc.,  are  poisons. 

Especially  should 
be  mentioned  alpha 
and  beta  naphthy- 
lamin,  benzidin, 
tolidin,  paianitra- 
nilin,  the  diamins 
(phenylene  and  tol- 
ylene  diamin)  as 
well  as  the  alphyl 
and  aryl  com- 
jjounds  of  anilin, 
like  their  homo- 
logues  (dimethyl 
and  diethyl  anilin, 
diphenylamin,  etc.). 


Manufacture  of  ani- 
lin and  its  deriva- 
tives, as  well  as  of 
anilin  dyes:  manu- 
facture of  photo- 
graphic materials 
and  the  like. 


Absorption 
through  the 
skin  by  di- 
rect contact 
or  by  satura- 
tion of  the 
c  lothing; 
through  the 
digestive  or- 
gans; absorp- 
tion through 
the  respira- 
tory organs 
as  volatile 
particles  and 
impalpable 
dust. 


The  toxirity  of  the  separate  products 
is  very  different  in  degree ;  the  para 
compounds  are  usually  more 
poisonous  than  the  ortho  and  meta 
compounds. 

Acute  Poisoning. — (a)  Mild 
cases:  Pallor  of  the  skin  and 
mucous  membranes,  with  slight 
cyanosis;  a  feeling  of  weariness  and 
weakness;  head  symptoms — ver- 
tigo, reeling,  unsteady  gait;  defi- 
cient elasticity  of  movement;  slow, 
labored  speech ;  irritability  (anilin 
"pip");  condition  of  slight  inebri- 
ation, with  loquacity,  gaiety,  and 
defective  power  of  orientation;  loss 
of  appetite,  constipation,  and 
tense,  rapid  pulse. 

(6)  Severe  cases:  Dark  blue  to 
swarthy  cyanosis;  formation  of 
methemoglobin;  bounding  pulse; 
"air-hunger,"  with  great  frequency 
of  respiration;  lowering  of  sensi- 
bility; obliteration  of  the  reflexes; 
sometimes  vomiting,  strangury  and 
bloody  urine. 

(c)  In  the  most  serious  cases: 
Sudden  prostration;  cold,  pale 
skin,  blue  lips,  nose  and  ears; 
diminution  and  even  extinction  of 
sensibility;  moist,  cold  skin;  small 
pulse;  death  in  a  comatose  condi- 
tion, sometimes  after  antecedent 
convulsions. 

StTBACtTTE  AND  ChRONIC  POISON- 
ING.— Anemia;  slowing  of  the 
pulse;  disorders  of  digestion,  such 
as  eructations,  loathing  of  food, 
vomiting,  diarrhea,  and  eczematous 
and  pustular  eruptions  on  various 
parts  of  the  body,  especially  on  the 
scrotum;  nervous  symptoms,  as 
general  debility,  headache,  ringing 
in  the  ears,  vertigo,  unrestful  sleep, 
disturbances  of  sensibility,  often 
also  of  motility;  spasmodic  muscu- 
lar pain.  Subacute  and  chronic 
poisonings  are  very  rare.  Anemia 
and  retarded  pulse  are  early 
symptoms. 

The  blood  is  of  a  brownish  hue, 
but  microscopically  unchanged ; 
occasionally  the  urine  contains 
blood. 


Measures  of  relief:  At  the  first  symptoms  of  poisoning,  immediate  removal  from  the  workroom  to 
a  cool  shady  spot;  change  of  clothing;  cool  affusions;  administration  of  oxygen  in  connection  with 
artificial  respiration;  in  severe  cases,  bloodletting  with  subsequent  infusion  of  physiological  salt 
solution;  cooious  ingestion  of  milk;  in  case  of  weak  action  of  the  heart,  stimulants  (black  coffee, 
camphor,  ether,  but  no  alcohol);  caution  against  the  use  of  alcohol  during  and  immediately  after 
labor;  abstinence  is  advisable.  ^ 


27G 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


ANILIN  DYE- 
STUFFS:  The  ma- 
jority of  the  very 
numerous  anihn 
dyes  are  non-poi- 
sonous. Generally 
the  basic  dyes  are 
more  dangerous 
than  the  acid  dyes. 

Regarded  as  sus- 
picious or  injurious 
to  health  are — 

(a)  The  various 
phenol  nitrates,  di- 
nitrophenol,  dini- 
trocresol  (saffron 
yellow, _  anilin 
orange),  picric  acid 
(trinitrophenol) . 


(6)  The  many 
naphthol  nitrates, 
dinitronaphthol, 
Manchester  yellow, 
dinitro  and  naph- 
thol calcium;  tet- 
ranitronaphthol. 

(c)  The  nitroso 
dyes. 


(d)  The  aurantia 
—  hexanitrodi- 
phenylamin;  im- 
perial yellow, 
sodium  salt. 

(e)  Ethyl 
methyl  violet. 


its 
and 


(.0  The  Meldola 
dyes,  corvulin,  in- 
dulin,  fast  black. 


(g)      Chrysoidin, 
fast  black. 


(h)  Bismarck  blue 


Anilin  dye  factories; 
dyehouses;  also 
manufacture  of  ex- 
plosives. 


Anilin     dye      manu- 
factories; dyehouses. 


Anilin      dye      manu- 
factories; dyehouses. 


Anilin      dye      manu- 
factories; dyehouses. 


Anilin  dye  manu- 
factories; dyehouses; 
manufacture  o  f 

colored  pencils. 

Anilin  dye  manu- 
factories; dyehouses. 


Anilin      dye      manu- 
factories; dyehouses. 


Anilin      dye      manu- 
factories; dyehouses. 


Action  on  the 
skin;  in  the 
form  of  dust, 
through  the 
respiratory 
organs;  the 
digestive  or- 
gans. 


Action  on  the 
skin;  in  the 
form  of  dust, 
through  . the 
respiratory 
organs;  the 
digestive  or- 
gans. 

In  the  form  of 
dust  on  the 
skin. 

In  the  tortii  of 
dust  on  the 
skin. 


As  dust  or  fine 
particles  in 
the  eyes. 

As  dust  or  at- 
omized solu- 
tion (in  dye- 
ing by  the 
spraying  pro- 
cess) ;  action 
on  the  skin 
and  respira- 
tory organs. 

In  the  form  of 
dust;  effect 
on  the  skin. 


ANTIMONY  COM- 
POUNDS : 
Trioxid  of  antimony, 

SbiOs; 

Antimony  trichlorid, 
SbCh  (antimon- 
ious  chlorid,  butter 
of  antimony,  anti- 
monial  ore  butter) ; 

Tartar  emetic  (tar- 
trate of  antimony 
and  potassium), 
2  (C4H4K[SbO]Oc) 
HoO; 

Golden  sulphid, 
SbaSs  (antimony 
pentasulphid),  an- 
timony colors. 


Extraction  of  anti-  In  the  form  of 
mony  and  its  com-  vapor  (trioxid 
pounds;  burnish-  of  antimony, 
ing  of  rifle  barrels  antimonious 
and  steel  ware;  acid,  sulphid 
manufacture  of  of  antimony) 
antimony  alloys,  through  the 
type  and  stereo-  organs  of  res- 
type  metal,  hard  piration;  irri- 
lead  [ammunition  tation  of  the 
factories],  britan-  skin;  in  the 
nia,  and  white  form  of  dust, 
metal;  remelting  in  the  ma- 
of  old  and  scrap  nipulation  o  f 
metal;  manufac-  britannia  and 
ture  of  anilin  type  metal, 
dyes,  fireworks ; 
vulcanizing  and 
red-dyeing  of  India 
rubber  (antimony  pentasulphid) ;  mor 
dyeing  and  textile  printing. 


Itching,  dermatitis,  efHorescent  erup- 
tion, yellow  discoloration  of  the 
cuticle  and  conjunctiva;  sneezing 
and  nasal  catarrh;  inflammation  of 
the  buccal  mucous  membrane; 
bitter  taste;  disturbances  of  diges- 
tion; irritation  of  the  central  nerv- 
ous system  and  of  the  kidneys. 
Picric  acid  is  a  feeble  former  of 
methemoglobin;  industrial  poi- 
sonings by  it  are  extremely  rare. 
Blood  poisons,  forming  methemo- 
globin. The  morbid  symptoms 
resemble  those  in  poisoning  by 
amido  compounds;  ailments  of  the 
central  nervous  system  in  great 
variety;  paralyses. 


Intense  irritation  of  the  skin,  caused, 
it  is  asserted,  partly  by  using 
excessive  quantities  of  chlorid  of 
lime  in  cleansing  the  skin. 

Intense  irritation  of  the  skin,  caused, 
it  is  asserted,  partly  by  using 
excessive  quantities  of  chlorid  of 
lime  in  cleansing  the  skin. 

Inflammation  of  the  conjunctiva  or 
the  cornea. 


Eruptions;  severe  irritation  of  the 
mucous  membranes;  uncontroll- 
able sternutation. 


Eruptions  (probably  superinduced 
by  the  use  of  excessive  quantities 
of  the  chlorid  of  lime  in  washing 
the  hands). 


Intensely  itching  eruptions  of  the 
skin,  caused  by  local  irritation  and 
aggravated  in  the  case  of  a  per- 
spiring skin;  inflammation  of  the 
mouth,  throat,  and  stomach;  con- 
stipation and  intestinal  colic;  in 
acute  cases,  diarrhea,  albumin  in 
the  urine,  loss  of  strength,  weak- 
ness of  the  heart,  vertigo,  and 
faintness. 

It  appears  to  be  somewhat 
doubtful,  however,  whether  all  of 
the  enumerated  compounds  of 
antimony  are  detrimental  to  the 
health  of  the  workers  in  them. 


dants  and  fixing  materials  in  cotton 


HEALTH  HAZARDS  IN  OCCUPATIONS 


277 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


ARSENIC  COM- 
POUNDS: Arsenic 
trioxid,  AS2O3  (ar- 
senic, white  arsenic, 
smelting  dust) ; 

arsenous       chlorid, 
AsCls;   arsenic   col- 
ors, e.g. — 
Scheele's         green 
(Swedish      green), 
arsenite  of  copper. 
Schweinfurt    green 
(patent,     original, 
new,  moss,  moun- 
tain, oarrot,  May, 
Kaiser,         Cassel, 
Paris,  Vienna, 

Kirchberg,  Leipsic, 
Wiirzburg,  Swiss 
green),  compound 
of  the  arsenite  and 
the  sulphid  of  cop- 
per. 
Brunswick  green, 
oxychlorid  of  cop- 
per with  cODper 
oxid  and  sulphate 
of  lime. 
Neuwied  green. 
(Similar,  only  a 
larger  proportion 
of  ars  nic  trioxid.) 
Cochineal  (Vienna 
red),  arsenic  acid 
with  extract  of 
Pernambuco 
wood. 


Mode  of 

entrancf 

into  the  body 


Arsenic  mining;  In  the  forms  of  Acute  Poisoning. — The  first  symp- 
roasting  of  arsenic-  gas  and  dust,  tonis  usually  appear  after  half  an 
bearing  ores;  manu-  through  the  hour  or  an  hour,  viz.,  constriction 
facture  of  glass,  respiratory  of  the  esophagus,  pains  in  the 
colored  chalk,  chlo-  organs  and  stomach  and  bowels,  vomiting, 
rid  of  arsenic  for  mucous  mom-  diarrhea,  debility,  cold,  bluish 
etching  on  brass;  branes,  the  skin,  sural  cramp,  lowering  of 
shot  manufacture;  stomach,  and  heart's  energy, _  vertigo,  headache, 
metal  working;        intestinal       fajntness,    illusions,    loss    of    con- 

manufacture  of       canal.  sciousness,      convulsions;      death, 

arsenic   colors;  sometimes     choleraic     symptoms, 

preparation     of     or-  In     mild     cases,     burning    in     the 

ganic  dyestuffs,  pharynx,       vorniting,       salivation, 

colored    lights,    tex-  difficult    deglutition    and    indiges- 

tile     printing,     and  tion. 

dyeing;        manufac-  Chronic  Poisoning. — -Constant 

ture    of    wall    paper  and  persistent  headache  combined 

and    colored    paper;  with     melancholia,     disinclination 

tanning;  manu-  to  labor,   and  sleeplessness,   which 

facture     of     oilcloth  are  sometimes  the  only  symptoms; 

and    artificial    flow-  further,  gastric  disturbances,  such 

ers;  taxidermy  as   vomiting    and   diarrhea,   which 

painting         (outside  result  in  emaciation  and  decline  of 

and  decorative);  strength;   persistent   symptoms   of 

pyrotechnics        (In-  catarrh  of  the  mucous  membranes, 

dian  white-fire).  such    as    coryza,    pharyngitis    and 

It    is    to    be    ob-  bronchitis;  frequently  skin  diseases 

served      that      zinc,  in    varying    form:    Frytbematous, 

silver,       lead,       bis-  papular,    and    pustular   cutaneous 

muth,    copper,    and  eruptions,  which   also  produce  ab- 

the  commercial  scesses   with  infiltrated   and  indu- 

acids       often      con-  rated   borders;    falling   out   of  the 

tain     more     or    less  ha'r  and  nails;  melanosis — -that  is, 

arsenic.  -        the  deposition  of  a  brownish  pig- 

ment, not  containing  arsenic,  on 
the  neck,  trunk,  and  extremities. 
In  severe  cnoes  disturbances  of 
the_  central  nervous  system;  intense,  lightninglike,  lancinatre  riains;  formi- 
cation; furriness  of  the  skin;  impairment  of  the  sensibility;  chilliness;  weak- 
ness of  the  muscles,  also  unilateral  or  bilateral  paralysis,  and  often  loss  of  the 
tendon  reflexes;  sometimes  fever;  albuminuria.  The  paralyses  are  transient, 
or  they  may  last  for  years,  leaving  not  infrequently  permanent  disturbances. 


Syrriptfirris  of  poi.sorjing 


Special  measures  of  relief:  If  arsenic  has  been  ingested,  thorough  gastric  lavage  is  necessary;  then 
administer  at  once  by  the  mouth  five  tablespoonfuls  of  a  solution  of  calcined  magnesia  (70  g.  to  500  g. 
of  distilled  water);  afterward  give  a  tablespoonful  every  five  minutes  until  a  movement  of  the 
bowels  occurs;  the  internal  use  of  lime  water  also  is  recommended  for  rinsing  out  the  stomach  and 
as  an  antidote;  to  counteract  the  exhaustion,  cold  affusions,  rubbing,  hypodermic  injections  of  ether 
and  camphor.  1 

In  case  of  chronic  arsenical  poisoning:  Electric  vapor  baths  and  electrical  treatment  are  in  order; 
the  disturbances  of  the  stomach  are  to  be  treated  with  calcined  magnesia  and  unirritating  liquid 
nourishment  (milk,  milk  porridge,  rice  porridge,  salep) ;  the  cachexia,  by  fresh  air  and  nutritious  diet; 
in  paralyses,  use  iodin  preparations  and  electricity. 


ARSENIURETED 
HYDROGEN, 

AsHs:  A  colorless, 
extremely  offensive 
gas  with  the  odor  of 
garlic. 


This  gas  is  formed  In  the  form  of  a 
everywhere  when,  gas,  through 
in  the  use  of  arsen-  the  organs  of 
ical  acids  and  met-  respiration 
als,  hydrogen  is  (general! 
generated  for  tech-  mixed  with 
nical  purposes  (e.  hydrogen). 
g.,  the  filling  of 
children's  toy  bal- 
loons) ;  in  solder- 
ing and  etching 
with  arsenic-con- 
taining metals  or 
acids,  e.g.,  enamel 
ware  factories,  tin,  zinc,  and  lead 
plating  works;  imp'ire  iron  silicate, 
by  the  absorption  of  water,  develops 
arseniuretted  hydrogen. 


At  first  no  disturbances,  or  only 
slight  indisposition;  after  some 
hours,  chilliness,  vomiting  (food, 
bile,  then  blood),  pain  in  the  back, 
giddiness,  ringing  in  the  ears,  faint-' 
ness,  small  pulse,  bluish  discolora- 
tion of  the  mucous  membranes; 
labored  respiration;  urine  at  times 
dark  or  even  black,  containing 
blood  or  hemoglobin. 

After  twenty-four  hours,  yellow 
hue  of  the  skin  and  mucous 
rnembranes;  from  absorption  of 
biliary  fluids,  fetor  of  the  mouth 
(resernbling  garlic),  swelling  and 
sensitiveness  of  the  liver  and  spleen, 
headache,  delirium,  mortal  an- 
guish; death  or  slow  convalescence. 


Special  measures  of  relief:  Fresh  air  and  oxygen;  later  bloodletting;  use  of  an  alkalin  solution  of 
common  salt;  mild  alkalin  drink;  analeptics  (coffee,  camphor). 


1  Hydrated  sesquioxid  of  iron  is  not  mentioned. 


278 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Designation  of  the 
substance 


BENZIN :  A  n\ixture 
of  low-ebiillition 
portions  of  petro- 
leum, known  com- 
mercially under  vari- 
ous names,  e.g., 
petroleum,  benzin, 
ligroin,  gasolin. 


Branches  of  industry 

in  which  poisoning 

occurs 


Benzin  distillation; 
chemical  cleansing 
plants,  glove  clean- 
ing; removal  of  fat 
from  bones,  fat  sol- 
vent; lacquer,  var- 
nish, and  India 
rubber  industries; 
manufacture  of 

waterproof  mate- 
rials (application 
of  the  rubber  mass 
dissolved  in  ben- 
zin) ;  ornamental 
feather  factories; 
used  as  a  source  of 
power. 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


In  the  form 
of  vapor, 
through  the 
respiratory 
organs;  to  a 
less  extent, 
probably , 
through  the 
skin  also. 


Headache,  vertigo,  nausea,  vomiting, 
cough,  irregular  respiration,  weak- 
ness of  the  heart,  drowsiness,  and 
deep  sleep  with  cyanosis  of  the 
countenance,  coldness  of  the  skin 
and  complete  insensibility;  on 
awaking,  headache,  vertigo  and  de- 
pression, fibrillar  twitching  of  the 
.muscles,  trembling,  especially  of 
the  musculature,  as  if  from  chilli- 
ness. Benzoic  acid  is  found  in  the 
urine. 

Chronic  Poisoning. — Head- 
ache, flashes  before  the  eyes,  ring- 
ing in  the  ears,  psychosis  with 
excitement  and  a  state  resembling 
inebriation,  sensory  disturbances 
and  hallucinations  (but  the  prq- 
dromata  of  chronic  benzin  poi- 
soning will  also  appear).  The 
occurrence  of  chronic  poisoning  by 
benzin  has  been  contested. 

The  symptoms  vary  greatly  be- 
cause the  benzin  used  technically 
is  a  complex  mixture  and  not  al- 
ways of  the  same  composition. 

Special  measures  of  relief :  Removal  of  the  patient  into  fresh  air;  in  severe  cases,  stimulants,  Uke 
coffee,  camphor;  then  cold  affusions. 


BENZOL,  CrHe.      A 

very  unstable,  color- 
less fluid,  burning 
with  a  bright,  very 
sooty  flame)  ex- 
tremely volatile;  its 
homologues,  e.g., 
toluol,  xylol,  and 
cumol. 


Manufacture  of  ben- 
zol, its  homologues 
and  numerous 

derivates;  technic- 
al use  of  these 
products  in  the 
manufacture  of 

colors,  in  carbur- 
izing  illuminating 
and  water  gas,  in 
refining  and.  dis- 
solving of  caout- 
chouc, resins,  fats, 
alkaloids,  iodin, 

phosphorus,  and 

sulphur;  in  the  re- 
moval of  grease 
from  materials; 

dye  works,  laun- 
dries; lacquer  and 
varnish  factories; 
the  rubber  industry. 


In     the     form  I  Benzol,  its  homologues  and  the  rest 
of  vapor,       of   the   hydrocarbons   of   coal  tar, 

through  the  have  a  specific  affinity  for  the 
respiratory  central  nervous  system  and  a  gen- 
or<Tans;  re-  cral  action  on  the  protoplasm  of 
absorption  the  organic  cells  (fatty  degenera- 
through  the  tion).  Fernale  workers,  particu- 
skin.  larly  in  their  developmental  years, 

especially  at  the  timeof  menstrua- 
tion, are  more  susceptible  than  men 
to  the  poisoning,  and  in  an  extra- 
ordinary degree  to  the  subacute 
and  chronic  forms  of  it. 

Acute  Poisoning. — (a)  In  mild 
cases:  Cerebral  disturbances,  hum- 
ming in  the  ears,  giddiness,  somno- 
lence, a  condition  resembling  in- 
ebriation, vomiting  and  irritant 
cough,  slight  flushing  of  the  face. 
There  is  often  euphoria. 

(b)  In  severe  cases:  Symptoms  on 
the  part  of  the  central  nervous  sys- 
tem, muscular  tremor,  like  chilli- 
ness from  exposure  to  cold;  trem- 
bling of  the  whole  extremities; 
finally,  tonic  and  clonic  spasms; 
euphoria;  pale,  livid  skin;  lips  re- 
markably scarlet  hued;  blood 
bright  red,  thin.  Discolorations  of 
the  skin,  like  those  in  anilin  and 
nitrobenzol  poisoning,  are  wanting 
in  benzol  poisoning. 

(c)  In  the  most  violent  cases:  Hal- 
lucinations, delirium,  protracted 
unconsciousness,  and  death  in  tonic 
convulsions. 

Subacute  and  Chronic  Poison- 
ing.— Numerous  spots  of  extrava- 
sated  blood  in  the  skin  [petechia] 
similar  to  those  of  morbus  macu- 
losus,  together  with  severe  ane- 
mia; hemorrhage  from  the  mucous 
membranes — in  women,  from  the 
genitals;  fatty  degeneration  of 
the  internal  organs  (heart,  liver, 
kidneys). 

Special  measures  of  relief :  Prompt  removal  of  the  patient  into  the  fresh  air;  inhalation  of  oxygen; 
exclusion  of  female  workers  from  every  employment  in  which  benzol  is  used. 


HEALTH  HAZARDS  IN  OCCUPATIONS 


279 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoninK 


CARBON    DIOXID, 

CO2:  A  specifically 
dense,  odorless,  col- 
orless gas,  collect- 
ing near  the  ground 
or  floor. 


In  the  forii 
gas,     by 
halation. 


Generated  in  mines  In  the  form  of 
by  the  process  of 
breathing,  by  the 
burning  of  miners' 
lamps,  and  by 
blasting;  in  lime 
and  brickkilns  and 
dolomite  calcining 
kilns;  in  decompo- 
sition and  putre- 
faction gases;  in 
tanneries^  (tan 

pits) ;        in        sugar 
mills  (saturation 

vessels);  manufacture  of  carbonic 
acid  and  of  mineral  waters;  spirit  dis- 
tilleries, compressed  yeast  factories, 
breweries,  fermenting  rooms  and 
wine  cellars;  in  sewer  and  well  gases; 
in  firing  and  heating  establishments; 
in  the  lighting  of  workrooms;  by  the 
exhaled  air  in  closed  workrooms  and 
caissons. 


Large  quantities  occasion  sudden 
death  by  suffocation. 

With  the  inhalation  of  smaller 
quantities  the  symptoms  of  illness 
begin  with  pressure  in  the  head, 
vertigo,  ringing  in  the  ears  and 
sparks  before  the  eyes,  disturbances 
of  respiration,  such  as  hurried 
breathing  and  pain  in  the  chest, 
sometimes  psychic  excitement  and 
convulsions.  Usually  in  case  of 
more  protracted  effect  there  is  loss 
of  consciousness  and  of  the  power  of 
motion  (or  even  death  by  suffoca- 
tion), with  gradual  decline  of  the 
pulse  and  respiration,  and  often 
with  the  occurrence  of  delirium. 

On  prompt  removal  from  the 
poisonous  atmosphere  there  is  a  res- 
toration of  consciousness  with  sub- 
sidence of  the  symptoms  of  illness 
and  recovery  in  a  few  days. 

The  occurrence  of  chronic  poison- 
ing by  carbon  dioxid  is  doubtful. 

Special  measures  of  relief:  Examination  of  the  air  of  the  suspected  places  before  entering  them ; 
immediate  removal  from  the  poisonous  atmosphere;  artificial  respiration  to  be  persevered  in  for 
a  long  time;  finally  inflation  of  the  lungs  with  oxygen;  cold  affusions;  stimulation  of  the  sldn; 
restoratives. 


CARBON  DISUL- 
PHID  (carbon  sul- 
phurate), CS2:  In  a 
pure  state  it  is  a 
limpid,  highly  re- 
fractive, extraordi- 
narily volatile  fluid, 
having  an  odor  like 
that  of  chloroform; 
imperfectly  refined, 
its  hue  is  pale  yel- 
low and  its  odor 
offensive. 


Manufacture  of  CS;; 
an  agent  for  ex- 
traction of  sulphur 
from  the  mass  in 
the  process  of  gas 
purification;  dis- 
infection; a  sol- 
vent for  caoutchouc, 
gums,  _  fats,  oils, 
etc.;  in  vulcaniz- 
ing caoutchouc 
and  rubber  (pat- 
ent-rubber facto- 
ries) ;  for  the  ex- 
traction of  lanolin, 
the  refining  of  tal- 
low, stearin,  paraf- 
fin, and  wax;  pro- 
duction of  carbon 
chlorid;  assembling 
and  setting  up  car- 
riage wheel  rims  and 
rubber  tires;  imi- 
tation-silk factories. 


In     the     form     It  causes  heavy  damage  to  the  red 

of  vapor,       blood  corpuscles  and  to  the  central 

through    res-       nervous  system. 

piration;        ir  Acute        Poisoning. — In    mild 

fluid        form,       cases,   marked  stupefaction  and  a 

through     the       sense  of  intoxication;  in  more  in- 

skin,    e.g.,   at       tense  poisoning,  pallor  of  the  coun- 

the  dipping  of      tenance,  flaccidity  of  the  arms  and 

the  hands  in       legs,    even    complete   insensibility, 

the  fluid.  obliteration  of  all  reflexes,  loss  of 

consciousness,  due  to  paralysis  of 

the  ce_ntral  nervous  system.     With 

the     inhalation     of     concentrated 

vapor  there  is  a  fatal  result  in  a  few 

minutes. 

Chronic  Poisoning. — The  ear- 
liest    symptoms     (first     becoming 
manifest,  sometimes  after  employ- 
ment for  a  few  weeks,  but,  for  the 
most  part,   after  months   or  even 
years)     are     headache,     extending 
from  the  root  of  the  nose  to  the  tem- 
ples, a  sensation  of  giddiness  and 
stupefaction,  particularly  at  even- 
ing  after   the  close  of  labor;  later, 
pain  in  the  extremities,   muscular 
weakness   with   trembling,   spasms 
or  fibrillar  twitching,  also  contractures,  transient  and  permanent  paralyses, 
with  atrophy  of  the  muscles;  deafness;  itching  and  formication  on  the  skin, 
reduction  of  the  reflexes,  circumscribed  and  more  extensive  areas  of  .anes- 
thesia and  analgesia;  acceleration  of  the  heart's  action,  nausea,  vomiting, 
colic,  alternate  diarrhea  and  constipation,  the  later  condition  prevailing  in 
the  later  stages  of  the  disease;  einaciation,  disturbance  of  the  sense  of  vision, 
sometimes   transient,   but   rare   in   the   initial   stage;   retrobulbar   neuritis, 
choroiditis,  central  scotoma,  disturbances  of  the  senses  of  smell  and  taste.   In 
respect  to  the  central  nervous  system  there  is  at  first  a  condition  of  excite- 
ment,  followed  by  depression;   subseauently,   very  irritable,   violent,   and 
explosive  temper,   with  hyperstimulation  of  the  sexual  instinct;  later,  its 
abnormal  decline.     After  several  weeks  or  months,  relaxation,  melancholy, 
a  dreamy  manner,  weakness  of  memory,  puerile  enunciation,  obtuseness. 

According  to  Charcot,  psychic  disturbances  occur  in  Sf.S  per  cent,  of  the 
cases.  Mental  diseases  under  the  semblance  of  acute  mania  and  dementia 
occur  with  good  prospect  of  recovery;  the  severer  forms  appear  in  cases  where 
there  is  hereditary  predisposition.  There  have  been  observed  also  local  evi- 
dences of  the  paralyzing  effect  of  the  carbon  disulphid  upon  the  parts 
brought  into  contact  with  it,  especially  in  the  fingers. 

The  prognosis,  so  far  as  the  preservation  of  life  is  concerned,  is  favorable; 
as  to  the  full  restoration  of  health,  it  is  unfavorable. 

Special  measures  of  relief:  In  acute  poisoning,  removal  into  the  fresh  air,  warm  baths,  cold 
affusions;  when  there  are  symptoms  of  paralysis,  electrical  treatment;  in  disturbance  of  vision, 
potassium  iodid  and  vapor  baths;  interdiction  of  the  practice  of  dipping  the  unprotected  hands 
into  carbon  disulphid. 


280 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Designation  of  the 
substance 


CARBON        MON- 
OXID,  CO:  A  color- 
less,   tasteless    gas, 
and,  when  in  a  state 
of    diffusion,    odor- 
less, burning  with  a 
blue  flame  in  the  air. 
Coal  vapor  has  from 
0.5  to  5  per  cent, 
of  CO. 
Illuminating  gas,  6 
to  10  per  cent,  of 
CO  and  33  to  40 
per  cent,   of  mine 
gas. 
Water  gas,  a  mix- 
ture of  41  per  cent. 
CO,    50   per   cent, 
hydrogen,     4     per 
cent.    CO2,   and   5 
per  cent.  N. 
Producer   gas    con- 
tains 34  per  cent. 
CO,    and    60    per 
^  cent,  hydrogen 
gas. 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


In  industrial  plants 
with  defectively 
planned  or  ill- 
tended  firing  and 
heating  arrange- 
ments; plants  for 
the  production  of 
industrial  gas;  min- 
ing (mine  gases) ; 
coal  mines:  blast 
furnaces  (furnace 
gas) ;  Cowper  appa- 
ratus; gas  purifica- 
tion; coke  ovens, 
smelting  furnaces; 
gas  machines;  lime 
and  brick  kilns, 
dolomite  calcining 
kilns;  iron  and 
metal_  foundries 
(drying  of  the 
molds);  soldering 
in  tin  shops:  char- 
coal burning;  resin 
distillation:  iron- 
ing; heating  with 
open  coal  brasiers 
or  coke  stoves  (dry- 
ing the  plaster 
and  walls  of  new 
iMiildings) ;  drying 
chambers. 


In  the  form  of 
gas,  through 
the  respira- 
tory organs. 


Symptoms  of  poisoning 


AcTJTE  Poisoning. — Increased  blood 
pressure  at  first,  with  slowing  of 
the  pulse  and  pounding  heartbeat; 
later,  lowering  of  the  pressure,  with 
rapid  but  small  pulse,  and,  not  in- 
frequently, with  discrete  spots  of 
dilation  in  the  superficial  blood 
vessels.  Remarkably  pale  red  dis- 
coloration of  the  blood  and  of  the 
dilated  spots;  formation  of  carbon- 
monoxid  hemoglobin  is  demon- 
strable by  the  spectrum.' 

(o)  Disturbances  of  the  general 
health:  In  mild  cases,  dull  head- 
ache, flashes  before  the  eyes,  giddi- 
ness, ringing  in  the  ears,  nausea 
and  fullness  in  the  gastric  region. 

(b)  In  severe  cases:  Bluish  discol- 
oration of  the  skin;  spasmodic, 
wheezing  respiration;  sometimes 
tonic  and  clonic  convulsions,  more 
often  paralytic  symptoms,  either 
with  weakness  of  all  the  extremi- 
ties or  of  the  lower  only,  or,  indeed, 
of  only  single  groups  of  muscles, 
including  also  the  facial  muscles. 

The  convulsive  stage,  which  may 
be  altogether  absent,  is  succeeded 
by  the  stage  of  asphyxia,  with  sen- 
sory and  motor  disturbances,  in- 
voluntary voiding  of  urine,  semen, 
and  feces;  subnormal  temperature; 
weak,  slow  and  intermittent  pulse; 
loss  of  consciousness. 

As  sequels  there  have  been  ob- 
served pneumonias,  inflammations 
of  the  skin,  paralyses  and  psy- 
choses, the  last  two  often  pursuing 
an  unfavorable  course. 

Chronic  Poisoning  (among 
ironers,  firemen,  cooks,  etc.) — Fre- 
quent headaches,  dizziness,  nausea, 
vomiting,  coated  tongue,  weakness 
of  memory;  anemia  without  chlo- 
rosis; "hot  flushes,"  formication, 
palpitation  of  the  heart,  insomnia, 
general  debility  and  feebleness  of 
the  psychic  functions. 

Special  measures  of  relief:  Removal  from  the  poisonous  atmosphere;  admission  of  fresh  air; 
artificial  respiration,  with  inflation  of  the  lungs  by  oxygen  for  hours,  if  necessary;  keep  head  of  the 
injured  person  slightly  elevated;  subcutaneous  injection  of  ether;  camphor;  cold  aff^usions;  rubbing; 
mustard  poultice;  electrical  treatment;  insufflation  of  ammonia  vapor;  administration  of  black  coffee; 
alkalin  salt  infusion;  entering  where  CO  may  be  generated  only  when  protected  by  safety  masks 
and  by  a  constant  supply  of  air.  ,    ,     ,  ,  ,  •     •    ■     v  ui    *  j      * 1 

1  An  elementary  knowledge  of  the  function  of  the  hemoglobin  is  indispensable  to  an  understand- 
ing of  the  deadly  effect  of  the  transformation  of  hemoglobin  into  "carbon-monoxid  hemoglobin. 
When  so  changed,  it  is  useless  in  the  body,  for  it  can  no  longer  carry  and  distribute  oxygen  to  the 
tissues.  Hence  all  of  the  blood  charged  with  this  poison  is  virtually  destroyed— lost  to  the  systenj 
as  surely  as  if  it  had  escaped  from  a  severed  artery.  So,  if  a  considerable  proportion  of  the  blood 
becomes  saturated  with  this  gas,  death  is  inevitable,  not  by  suffocation,  as  commonly  imagined, 
but  by  carbon-monoxid  poisoning. — W.  II.  R. 

39538°— Bull.  100—12 2 


HEALTH  HAZARDS  IN  OCCUPATIONS 


281 


Designation  of  the 
substance 


CHLORID    OF 

LIME,  CaOCh:  A 
white  granular, 
somewhat  desicca- 
tive,  powder,  hav- 
ing the  odor  of  hy- 
pochlorous  acid, 
and  containing  35 
to  40  per  cent,  of 
chlorin. 


Branches  of  industry 

in  which  poisoning 

occurs 


Manufacture  of  the 
chlorid  of  lime;  use 
of  the  chlorid  of 
lime  as  an  oxidiz- 
ing and  chlorinating 
agent  in  the  chem- 
ical industry  (for 
example,  dyestuffs) ; 
disinfection;  manu- 
facture of  chloro- 
form, chlorin,  oxy- 
gen; bleaching  of 
linen,  cotton,  paper; 
cotton  print  works. 


Mode  of 

entrance 

into  the  body 


In  the  form  of 
vapor  or  dust, 
through  the 
respiratory 
organs  (in- 
halation of 
chlorin  gas) ; 
direct  action 
on  the  skin. 


Symptoms  of  poisoning 


More  or  less  severe,  irritating  cough, 
symptoms  of  inflammation  in  the 
upper  air  passages;  difficulty  of 
breathing,  bronchitis,  asthma, 
sometimes  hemoptisis,  irritation 
of  the  conjunctiva,  lachrimation; 
skin  hot  from  action  of  chlorin; 
hyperhidrosis;  intensely  itching 
and  burning  eruption  on  the  skin, 
eczema,  burns  from  the  dust  of 
lime  and  its  chlorid. 


Special  measures  of  relief:  Admission  to  the  employment  of  such,  and  only  such,  workmen  as  are 
sound  and  strong,  and  free  from  any  predisposition  to  catarrhal  affections;  technical  arrangements 
which  permit  the  charging  and  emptying  of  the  chambers  from  the  outside. 


CHLORIN,  CI:  A 
yellowish  green, 
suffocating  gas,  of 
penetrating  odor, 
which  forms  a  solu- 
tion of  a  greenish 
yellow  color  when 
dissolved  in  water. 


Manufacture  of  chlo- 
rin, chlorid  of  lime, 
and  of  organic  chlo- 
rin products;  bleach- 
eries;  paper  mills; 
laundries;  ironing; 
tinning  works; 

manufacture  and 
use  of  disinfecting 
agents  containing 
chlorin. 


In  the  form  of     The  smallest  quantities  excite  severe 

gas,    through       suffocative    sensations    and    neces- 

the      respira-       sitate   leaving   the   room,    so    that 

tory  organs.  acute     chlorin     poisoning     seldom 

occurs. 

Symptoms  op  Cutaneous  Dis- 
ease.— Burning,  stinging,  forma- 
tion of  nodules,  blebs,  and  even 
open  wounds  of  the  skin. 

Eppect  on  the  Mucous  Mem- 
branes.— Lachrimation,  coryza, 
cough,  oppression  of  the  chest  and 
intense  dyspnea;  bronchial  ca- 
tarrh with  hemorrhage;  sometimes, 
lobular  pneumonia.  The  concen- 
trated vapor  causes  uncontrollable 
cough,  spasm  of  the  glottis,  dysp- 
nea, cold  sweats,  cyanosis  and 
small  pulse;  death  occurs  within  a 
few  minutes  (sudden  collapse). 

In  its  Chronic  Effect. — Dis- 
tress in  the  gastric  region;  chronic 
catarrh  of  the  stomach;  pyrosis; 
pallid  countenance;  catarrh  of  the 
respiratory  tract;  lobular  pneu- 
monia; headache,  vertigo,  insom- 
nia; gradual  emaciation  and  pre- 
mature senescence. 

Chlorin  Acne. — (Occasioned 
in  the  electrolytic  production  of 
chlorin  by  chlorinated  carbu- 
reted hydrogen.)  Inflammatory 
processes  in  the  dermal  glands; 
the  occurrence  of  unusually  diffuse, 
confluent  comedones  with  indu- 
rated, dark-green  heads;  solid  infil- 
tration of  the  sebaceous  follicles, 
their  inflammation  and  suppura- 
tion causing  pustules  and  boils. 

Special  measures  of  relief:  Removal  of  the  patient  into  the  fresh  air;  inhalation  of  amyl  nitrite; 
artificial  respiration;  on  account  of  the  paralyzing  effect  of  the  chlorin  on  the  heart,  stimulants  are 
required  (black  coiTee,  subcutaneous  injection  of  camphorated  oil);  to  control  the  irritating  cough, 
hypodermics  of  morphin  or  cautious  inhalation  of  steam. 

For  the  prevention  of  chlorin  acne:  Substitution  of  anodes  made  of  molten  metallic  oxides  for  the 
carbon  anodes. 


CHLORODINI- 
TROBENZOL,   Ce- 

H3(N02)2C1:  Form- 
ing yellow  crystals. 
(See  Nitrobenzol.) 
CHLORONITRO- 
BENZOL,  CeHj- 
NO2CI:  Forming 
yellowish  crystals  of 
aromatic  odor.  (See 
Nitrobenzol.) 


282 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Designation  of  the 
substance 


CHROMIUM  COM- 
POUNDS :  Chromic 
acid,  anhydrous^ 
CrOs;  chromates 
and  bichromates, 
e.g.,  sodium  chro- 
mate,  Na»Cr04;  so- 
dium bichromate, 
Na2Cr207;  lead 

chromate,  PbCr04. 
Chromium  colors : 
Chrome  yellow 
(acid  chromate  of 
lead);  chrome 
orange  (basic  and 
neutral  chromate 
of  lead) ;  chrome 
red  (ciarome-cin- 
nabar) ;  acid  chro- 
mate of  lead  oxid 
and  lead  hydrate; 
chrome  green,  poi- 
sonous only  as  a 
mixture  of  chrome 
yellow  and  paris 
blue.  (See  also 
under  Lead.) 


Branches  of  industry  i         Mode  of 
in  which  poisoning  entrance 

occurs  into  the  body 


Symptoms  of  poisoning 


Manufacture  of  Absorption  by  The  chromates  act  very  much  like 
chromium  prepara-  the  skin  and  chromic  acid  itself;  pithke,  phage- 
tions,  chrome  colors,  mucous  mem-  denic  ulcers,  burrowing  deep  and 
and  hectograph  branes;  in  spreading  wide,  very  difficult  to 
composition;  pho-  the  form  of  heal  and  very  painful,  occur  almost 
tography  (color  and  dust,  through  exclusively  on  the  skin  of  the 
carbon  printing);  the  respira-  hands,  more  rarely  on  the  arms, 
oxidizing    agent    in       tory  organs.  thighs,  scrotum,  and  penis,  resem- 

the      tar-color      in-  bhng    syphilitic    ulcers;  they  also 

dustry ;  manufacture  appear,     though     seldom,     on   the 

of  matches;  wet  bat-  mucous   membrane   of   the   tonsils 

teries;  bleaching  and  of  the  hard  and  the  soft  palate. 

fats    oils    and  wax;  With  rare  exceptions  is  there  exten- 

mor'dant'  in    Turk-  s^oii  of  ^^^  inflammation  to,   and 

ish       red       dyeing,  perforation    of,    the   nasal   septum 

textile  printing   (for  ^^  ^h^  cartilaginous  portion;  ecze- 

neutralizing      colors  matous  eruptions, 

and      for      dyeing);  Irritation  of  the  conjunctiva, 

chrome     tanning  Iheitation    op    the    Bronchi- 

(two-vat      process);  oles. — Chronic  bronchial  catarrh, 

staining  of  wood.      '     •  ^^id  small  areas  of  inflammation  in 

the  lungs.  _  In  recent  years  the 
last  mentioned  symptoms  are 
hardly  ever  encountered  in  a 
remarkably  wide  field  of  observa- 
tion. It  is  at  least  extremely 
doubtful  if  disease  of  the  kidneys 
is  ever  caused  by  chromium. 

In  handling  chromium  dyes  con- 
taining lead  there  is  danger  of 
chronic  lead  poisoning. 

Special  measures  of  relief:  Chromium  ulcers  are  successfully  overcome  by  careful  treatment  of  the 
slightest  injuries  to  the  skin,  and  by  the  immediate,  complete,  and  skillful  closure  of  the  lesions. 


CYANOGEN  COM- 
POUNDS: Dicy- 
anogen,  C2N2;  Prus- 
sic  acid,  HCN:  Hy- 
drocyanic acid,  a 
colorless,  highly 
volatile  fluid,  of 
penetrating,  _  pun- 
gent, and  irritating 
odor. 

Natrium  cyanid 
(NaCN),  Cyanid 
of  potassium 
cyanid  (KCN):  A 
colorless  salt,  form- 
ing crystals  which, 
after  fusion,  re- 
crystallize,  but 
readily  d  e  c  o  m- 
poses  on  exposure 
to  the  air,  setting 
free  hydrocyanic 
acid. 
Rhodanic  (sulpho- 
cyanic,  SCN) 
compounds :  Poi- 
sonous dose  of  the 
dilute  hydrocyanic 
acid,  0.06  g. 


Extraction  of  gold ; 
silver  and  gold 
plating,  g  a  1 V  a  n  o- 
plasty,  electroplat- 
ing; manufacture 
of  cyanogen  com- 
pounds and  inor- 
ganic processes 
(when  organic  resi- 
dua are  heated 
with  alkalis) ;  re- 
duction of  residu- 
um to  gas;  blast 
furnaces;  gas  works 
(purification  proc- 
ess), dye  works  and 
printeries;  photo- 
graphic establish- 
ments; manufacture 
of  celluloid. 


In  the  form  of     Generally  speaking,  industrial  poi- 
gas,    through       sonings  by  cyanogen  are  rare, 
the      respira-  Acute      Poisoning. — Moderate 

tory  organs;  quantities  of  the  gas  cause  vertigo, 
prussic  acid  headache,  rush  of  blood  to  the 
also  through  head,  oppression  of  the  chest,  pal- 
the  epidermis,  pitation  of  the  heart,  a  sensation 
'  of  constriction  at  the  throat  with 
pharyngeal  irritation  and  dryness, 
nausea  and  vomiting,  difficult, 
gasping  respiration,  with  reten- 
tion of  consciousness.  To  the  stage 
of  dyspnea  succeeds  that  of  spasm 
with  cold,  perspiring  skin,  convul- 
sions and  involuntary  micturition, 
with  loss  of  consciousness.  In  the 
stage  of  asphyxiation  there  are  tem- 
porary suspension  of  respiration, 
retardation  of  the  heart's  action, 
lividity  of  the  skin  and  mucous 
membranes,  lowering  of  the  body 
temperature;  with  inhalation  of 
large  quantities,  the  stage  of  as- 
phyxia supervenes  immediately. 
Dilation  of  the  pupils;  loss  of  con- 
sciousness; a  few  gasping  inspira- 
tions; cyanosis  of  the  skin  and 
mucous  membranes;  collapse; 
death. 

Chhonic  Poisoning  (Very 
doubtful) . — Headache,  vertigo,  un- 
steadiness of  gait;  nausea,  loss  of 
appetite,  disturbances  of  the  gas- 
tric and  intestinal  functions;  slow- 
ing of  the  pulse;  albuminuria. 

Special  measures  of  relief:  Fresh  air;  artificial  respiration;  administration  of  oxygen;  cold  affusions 
and  friction;  hypodermatic  injection  of  ether,  camphor;  if  the  poison  has  been  taken  into  the  stom- 
ach, give  emetics,  then  immediately  rinse  out  that  viscus  with  water,  with  the  addition  of  one- 
quarter  to  one-half  of  1  per  cent,  of  potassium  permanganate.  Kobert  recomrnends  a  3  per  cent, 
solution  of  hydrogen  binoxid  for  subcutaneous  injection,  in  doses  of  1  cubic  centimeter,  at  different 
points  in  the  body.  But  on  the  other  hand  H2O2  is  deemed  unsuitable,  and  an  alkalin  solution  of 
ferric  sulphate,  or  an  antidote  for  arsenic  with  some  ferric  salt,  is  indicated  as  the  best  remedy. 
To  control  the  convulsions  give  morphia  hypodermically. 


HEALTH  HAZARDS  IN  OCCUPATIONS 


283 


Designation  of  the 
substance 

Branches  of  industry 
in  which  poisoning 
occurs 

Mode  of 

entrance 

into  the  body 

Symptoms  of  poisoning 

DIAZOMETHANE, 
CH2NH2:     A     very 
volatile  yellow  gas. 

In      methylizing      of 
every  kind. 

As  gas,  through 
the  lungs;  ef- 
fect    on     the 
skin. 

Acute  Poisoninq. — Severe  head- 
ache; great  physical  depression; 
grave  lesions  of  the  lungs;  other 
effects  like  those  of  dimethyl  sul- 
phate. 

DIMETHYL     SUL- 
PHATE.      (CH.,)..- 
SOr.      A      colorless 
oily  fluid. 

Production  of  methyl 
ethers,  methyl  esters 
and  methyl  amines; 
manufjicture    of    ar- 
tificial perfumes. 

In  the  form  of 
gas,    through 
the      respira- 
tory   organs; 
direct    action 
on  the  skin. 

Strongly  corrosive  effect  on  the  skin 
and  mucous  membranes;  burns; 
pains  in  the  nape  of  the  neck  and 
in  the  thoracic  cavity;  hoarseness; 
destruction  of  the  mucous  mem- 
brane and  aspiration  of  the  broken- 
down  products  into  the  lungs;  lach- 
rimation,  conjunctivitis,  formation 
of  erosion-eschars,  and  edema, 
photophobia  and  parenchymatous 
clouding  of  the  cornea;  even  coma, 
convulsions,  paralysis,  and  a  fatal 
outcome. 

DINITROBENZOL 
or    BINITROBEN- 
ZOL,    C-,H.(NO-2)2: 
When  pure,  crystal- 
lizing    as     slender, 
colorless,     rhombic 
needles;    when   im- 
pure,  in   yellow, 
crystalline  cakes. 
(See  Nitrobenzol.) 

FORMALDEHYD, 

CH-.0:      A     liquid, 
volatilizing      as      a 
gaseous  _  vapor     of 
penetrating      odor; 
10  per  cent,  formal- 
dehyd,  formalin. 

Disinfection;      manu- 
facture     of      many 
organic    p  r  e  p  a  r  a- 
tions,    especially    in 
the    coal-tar     color- 
industry;       preserv- 
ing   and    hardening 
of  human  and   zoo- 
logical preparations. 

In     the     form 
of       vapor, 
through     the 
respiratory 
organs       and 
mucous  mem- 
branes. 

Intense  irritation  of  the  skin  and 
mucous  membranes. 

Special  measures  of  relief :  J)o  not  enter  the  disinfection  chamber  until  after  the  introduction  of 
ammonia  and  thorough  ventilation. 


HYDROCHLORIC 
ACID,  HCl:  Pure 
HCl  is  a  colorless 
gas  that  fumes 
when  ojjen  to  the 
air,  forming  a  dense, 
acid,  white  mist. 
The  crude  commer- 
cial hydrochloric 
acid  is,  for  the  most 
part,  impure,  con- 
taining arsenic, 
among  other  admix- 
tures. 


Treatment  with 
chlorin  of  previ- 
ously roasted  ores; 
potteries  (glazing), 
enameling  works, 
glass  factories,  sol- 
dering: in  the  chem- 
ical industry,  manu- 
facture of  chlorid 
and  sulphate  of 
soda.of  muriatic  acid, 
stannic  acetate,  etc.; 
manufacture  of  arti- 
ficial iertilizers; 
bleachng,  shoddy 
industry,  cotton- 
print  works;  car- 
bonizing of  mate- 
rials; India  rubber 
industry. 


Action  on   the     As  a  rule  the  rarefaction  of  the  hy- 
s  k  i  n       and       drochloric  acid  gas  is  so  consider- 
nasal  mucous       able  in  the  industries  where  it  is 
membrane;       used  to  any  extent  worth  mention- 
seldom     in       ing  that  only  in  exceptional  cases 
vaporous       do  injurious  effects  occur,  such  as 
form,    affect-       irritation  of  the  respiratory  organs, 
ing  the  respi-       A  proportion  of  0.05  per  mille  of 
ratory  organs,      hydrochloric  acid  in  the  air  is  well 
borne,  but  only  for  a  short  time.    A 
greater  concentration    (as   well   as 
the  often-repeated  inhalation  even 
of   moderate   quantities   in   manu- 
facturing industries)  causes  chronic 
irritation    of    the     mucous     mem- 
branes   to    which    the   vapor    has 
access.     There    result  also  catarrh 
of  the  conjunctiva,  coryza,  pharyn- 
geal,     laryngeal,      and     bronchial 
catarrh,      together      with      dental 
caries. 

Concentrated    HCl    vapor    may 
cause  unconsciousness  and  death. 

■  Special  measures  of  relief:  Removal  of  the  patient  from  the  dangerous  atmosphere;  inhalation  of  a 
finely  nebulized  solution  of  sodium  bicarbonate. 1 


'  In  addition,  for  acute  poisoning,  give  atropin  (>go  grain)  subcutaneously  to  stimulate  the 
pneumogastric. — W.  H.  R. 


284 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


HYDROFLUORIC 
ACID  or  FLUORIC 
ACID,  HF:  A  color- 
less gas,  of  pungent 
odor  and  forming  a 
dense  mist  in  the 
air. 


LEAD,  Pb:  A  bluish 
white,  highly  lus- 
rous  metal,  which 
on  exposure  to  the 
air  acquires  a  gray 
tarnish. 
Lead  alloys. 
Lead   colors,    other 

lead  compounds. 
Lead  sulphuret 
(galena)  is  held  to 
be  nonpoisonous, 
and  some  lead 
polysilioates  are 
regarded  as  nearly 


Production  in  chem-  In  the  form  of 
ical  works;  glass  gas,  through 
factories,  etching  the  respira- 
laborato-  tory  organs, 
ries  of  the  pottery  In  a  fluid 
industry;  extrac-  state  it  has 
tion  of  the  fluor-  an  immediate 
ides  of  antimony  action  on  the 
substitute  for  tar-  skin  and 
tar  emetic  in  dye-  mucous  mem- 
works);  fe  r  t  i  li  z  er  branes. 
factories  (extrac- 
tion of  phosphor- 
ites) ;  bleaching  of  cane  for  chair  seats 
and  extraction  of  its  silicates. 


Intense  irritation  of  the  eyelids  and 
conjunctiva,  coryza,  bronchial  ca- 
tarrh with  spasmodic  cough,  ulcera- 
tion of  the  nostrils,  gums,  and  oral 
mucous  membrane;  also  painful 
ulcers  of  the  cuticle,  erosions  and 
formation  of  vesicles;  suppuration 
under  the  finger  nails. 


Absorption  of  Industrial  lead  poisoning  appears  as 
lead  and  lead  a  rule  in  the  chronic  form  and 
compounds  arises  from  continuous  absorption 
occurs  —  of  the  most  infinitesimal  quantities 
(l)In  isolated  of  lead  during  a  protracted  period 
cases  through  of  time  (weeks,  months,  and  even 
the      skin;       years). 

whether  The  beginning  is  insidious,  with 

through  the  disturbances  of  the  general  health, 
uninjured  a  sense  of  weakness,  decline  of 
skin  is  doubt-  bodily  strength;  sallow,  pale-yel- 
ful;  (2)  in  the  lowish  hue  of  the  skin.  Distress  in 
form  of  vapor  the  region  of  the  stornach,  eructa- 
(very  finely  tions,  lack  of  appetite,  metallic 
divided  oxid  taste  in  the  mouth  and  fetid  breath, 
of  lead),  and  The  blue  line  (blue-gray  discolor- 

as         dust,       ation  of  the  gums)  which,  however, 
through     the       may  be  absent,  even  in  the  course 
respiratory       of  a  severe  attack;  lead  colic  with 
organs;        (3)        most  obstinate  constipation,  reten- 
by  way  of  the       tion   of   urine;    plumbic   arthralgia 
digestive       (lacerating,  boring),   occurring  for 
t  r  a  c  t  b  y       the      most      part      paroxysmally, 
means  of  con-       chiefly    in    the    lower    extremities, 
taminated       more  rarely  in  the  upper,  often  in- 
fo o  d  a  n  d       terpreted  as  a  symptom  of  rheuma- 
drinks        (for       tism  of  the  joints;  frequently,  fibril- 
ex  a  m  p  1  e  ,       lar  trembling  of  the  fingers.     Typ- 
cigars,     ciga-       ical  are  the  lead  paralyses,  of  which 
rettes,    chew-       disturbances    of    sensation    (pares- 
ing  tobacco).       thesia    and    anesthesia)    take    the 
By  inhalation       precedence.         Paralysis   generally 
the      d  u  st ,       affects  the  extensor  muscles  of  the 
laden        with       arm  and  hand,  with  atrophic  mani- 
lead,         finds       festations;  more  rarely,  the  flexor 
lodgment     in       muscles.     Sometimes  also  there  are 
the  upper  res-       paralyses  of  the  extensors  and  flex- 
piratory  tract,      ors  of  the  lower  extremities  or  mus- 
and,       mixed       cles  of  the  shoulder.      From  experi- 
with      saliva,       ence  it  is  known  that  those  groups 
may        reach       of   muscles  are   especially  affected 
the  stomach.         which  are  most  used  in  the  occupa- 
tional   activity.      Transient   blind- 
ness,   but   also    gradually   progres- 
sive atrophy  of  the  optic  nerve;  temporary  loss  of  the 
special  senses  of  smell  and  taste;  violent,  often  fatally 
ending   disease    of   the    brain    (saturnine    encephal- 
opathy), sometimes  preceded  only  by  slight  premoni- 
tory symptoms,  as  irritability  and  headache,  ringing 
in  the  ears,  insomnia;  more  often,  slowly  increasing 
mental   disturbances   precede;   epileptiform    convul- 
sions,  hallucinations;   morbid  changes  in  the  blood 
vessels   and    of   the   heart   and   kidneys    (contracted 
kidney);    increase    of   blood    pressure    and    granular 
degeneration  of  the  red  blood  corpuscles. 

Disturbances  in  the  sexual  sphere  in  women;  abor- 
tion, premature  birth,  low  vitality  of  the  children. 

Measures  of  relief:  Discontinuance  of  work  in  lead  at  the  slightest  symptoms  of  lead  poisoning. 
In  lead  colic,  give  first,  bv  the  mouth  or  sul)cutaneously,  morphia,  opium,  or  atropin;  afterward, 
cathartics  (castor  oil  or  podophyllin) ;  in  paralysis,  electrical  treatment,  massage  and  baths;  in  every 
case,  strengthening  diet,  iodid  of  potassium,  and  sudorifiices. 


Smelting  of  lead  and 
lead-bearing  ores; 
manufacture  and 
use  of  articles  made 
o  f  metallic  lead 
(sheets,  plates, 
boxes,  pipes,  wire, 
cans,  flasks,  pails, 
kettles,  faucets,  re- 
torts) ;  manufacture 
and  use  of  lead 
alloys,  as  type 
metal,  shot  (tin  foil), 
for  example,  in  type 
foundries,  tin  shops, 
bottle-cap  factories, 
composing  rooms, 
file-cutting  works; 
manufacture  and 
use  of  lead  colors 
and  other  lead 
compounds,  as  lith- 
arge, white  lead, 
Krems  white,  red 
lead,  lead  chro- 
mates,  acetate  of 
lead,  lead  chloride  in 
lead  color  works 
and  storage-battery 
factories,  in  the 
trade  of  painter, 
house  painter  and 
varnisher;  plants  for 
installation  of  gas 
and  water;  in  the 
ceramic  industry, 
the  textile  industry, 
etc. 

It  is  to  be  ob- 
served that  mate- 
rials containing  lead 
may  occasionally  be 
employed  in  every 
industry,  and  that 
lead  colors  and 
other  lead  com- 
pounds are  often 
met  with  in  trade 
under  fanciful 
names. 


HEALTH  HAZARDS  IN  OCCUPATIONS 


285 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


MANGANESE  DI- 
O  X  I  D  ,  MnOj: 
Brown  mineral  (oc- 
curring chiefly  as 
pyrolusite) . 


MERCURY,   Hg:   A 

silver-white,  shin- 
ing metal,_  un- 
changeable in  the 
air,  but  evaporating 
at  house  tempera- 
ture. 
Mercury        c  o  m- 

pounds,  amalgams 

(alloyswith 

metals) . 
Cinnabar   (HgS)   is 

nonpoisonous. 


Breaking  and  grind-  In  the  form  of  Mn02  produces  cumulative  efffcts. 
ing  of  manganese  dust,  through  After  protracted  action  of  the  toxin 
ore;  sifting  out  of  the  reapira-  the  symptoms  begin  with  dis- 
the  refuse.  tory  organs.  turbances    of    the    general    sensi- 

bility, general  debility,  languor, 
lancinating  pains  in  the  extremi- 
ties, in  the  small  of  the  back  and 
nape  of  the  neck,  creeping  sensa- 
tions in  the  legs  and  numbness  in 
the  feet;  salivation;  tremor  of  the  head,  tongue,  and  hands;  later,  locomotor 
disturbances  with  uncertain,  stamping  gait,  and,  ultimately,  the  impossi- 
bility of  safe  and  sure  progression. 

_  Affections  of  the  voice  (low,  whispering)  and  of  speech  ("indistinct,  scan- 
ning) combined  with  flatness  of  tone;  forced  laughter  and  weeping  and  low- 
ering of  intelligence. 

Sonietimes  dropsical  effusion  into   the    cellular   tissue    of    the   lower   ex- 
tremities. 


Mining  and  smelting 
of  quicksilver;  oc- 
cupation of  mirror 
plater,  amalgam 

gilding  and  silver- 
ing; manufacture 
o  f  thermometers, 
barometers,  and 
manometers,  i  n- 
candescent  electric 
lamps.  Roentgen 
and  Hittorf  tubes, 
mercurial  vapor 
lamps;  manufac- 
ture of  the  salts  of 
mercury,  a  m  a  1- 
gams,  and  colors, 
pharmaceutic  prod- 
ucts, antiseptic  dyes, 
inflammable  ma- 
terials, and  explo- 
sives; employment 
of  the  salts  of 
mercury,  especially 
in  the  hare's  fur 
business  and  felt-hat 
manufacture ;  pho- 
tography and  steel 
engraving. 


Absorption  Industrial  mercurial  poisoning  is  a 
through  the  chronic  poisoning  occasioned  by 
uninjured  work  in  this  metal  for  a  long  period, 
skin;absorbed  commonly  weeks,  months,  years,  or 
in  the  form  decades.  The  first  symptom  is 
of  vapor  and  generally  increased  ptyalism,  with 
dust  swelling  and  inflammation  of  the 
(amalgam  gums  and  of  the  buccal  mucous 
dust,  dust  of  membrane,  often  with  the  forma- 
t  h  e  CO  m-  tion  of  rodent  ulcers,  besides,  there 
pounds  o  f  are,  frequently,  disturbances  of 
mercury).  digestion,    lassitude,    and     pallor. 

Associated  with  the  further  absorp- 
tion of  mercury,  "erethism"  super- 
venes— a  peculiar  psychic  excita- 
bility (timorousness,  bewilderment, 
irritability)  aside  from  the  charac- 
teristic mercurial  tremor.  In  a 
state  of  complete  repose  this  tremor 
is  not  noticeable,  and  manifests  it- 
self only  on  voluntary  movement, 
causing  a  quite  distinctive,  irregu- 
lar tremulousness  of  the  fingers, 
hands,  arms,  and  finally,  also,  of 
the  legs  and  head.  In  strictly  chronic  cases  the  stom- 
atitis and  erethism  are  absent,  and  only  the  tremor  is 
observable.  Death  may  result  in  the  worst  cases  in 
consequence  of  the  violent  tremor  and  spasms  affect- 
ing the  entire  body;  in  other  cases,  increasing  weak- 
ness.    Cachexia. 


Special  measures  of  relief:  Relinquishment  of  the  employment;  nutritious  diet;  vapor  baths; 
potassium  iodid. 


METHYL  AL- 
COHOL (wood 
spirit),  CH3OH:  A 
colorless  fluid,  of 
faint  odor. 


Produced  by  the  dry     Ab  sorpt  ion 
distillation    of       through     the 
wood;    used    in    the       digestive    or- 
preparation   of   var-       gans,     also 
nish,     lacquer,     pol-       through     the 
ish,    and    perfumes;       skin;    in    the 
for    the    denaturing       form    of    va- 
of    spirits;    for    the       por     through 
production    of   coal-       the  organs  of 
tar  colors  and  phar-       respiration, 
maceutical       prepay 
rations;     a     solvent 
for    anilin    dyes    in 
cotton    print    manufacture;   used   in 
combination  with  shellac  for  coating 
the    interior    of    casks;    in    cabinet- 
making  and  furniture  polishing. 


The  effect  is  very  persistent;  nausea, 
headache,  ringing  in  the  ears,  weak- 
ness of  the  muscles,  insomnia,  deli- 
rium, difficulty  of  breathing,  and 
sometimes  deafness;  inflammation 
of  the  throat  and  the  mucous  mem- 
brane of  the  air  passages  extending 
to  the  finest  ramifications  of  the 
bronchial  tubes;  finally,  death  by 
paralysis  of  the  respiratory  appara- 
tus. Conjunctivitis;  also  serious 
affections  of  the  retina  and  the 
optic  nerve,  resulting  in  blindness, 
even,  from  atrophy  of  this  nerve.  1 
In  chronic  cases,  fatty  degenera- 
tion of  the  liver. 


Special  measures  of  relief:  The  substitution  of  innocuous  media  for  methyl  alcohol  in  the  denatur- 
ing of  spirits. 


1  Perrnanent  blindness  and  even  a  fatal  issue  may  be  caused  by  the  ingestion  of  small  quantites  of 
wood  spirit;  hence  the  risk  incurred  in  using  cheap  essences  of  vanilla  and  other  flavoring  extracts 
which  contain  methyl  alcohol. — W.  H.  R. 


286 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


METHYL  BROMID, 

CHsBr:  A  colorless, 

gaseous     body      of 

aromatic  odor. 

Methyl  iodid,  iodin 
methylate,  CH3I: 
An  ethereal,  color- 
less fluid,  of  some- 
what penetrating 
odor,  soon  becom- 
ing yellow  on  ex- 
posure to  the  air. 


Employed    in    anilin 
dye  factories. 


In  the  form  of 
gas,  through 
the  respira- 
tory organs 
and  the  mu- 
cous mem- 
branes. 


In  mild  cases,  vertigo,  headache,  and 
transient  stupor,  with  diplopia  and 
a  sensation  of  rigidity  in  the  mus- 
cles of  the  eyes. 

In  a  severe  case  there  was  ob- 
served loss  of  consciousness  continu- 
ing eight  weeks,  with  staring  look, 
pallor  of  the  skin,  retarded  pulse, 
and  obstinate  constipation.  Dur- 
ing brief  intervals  of  wakefulness 
there  was  unrest  with  increasing 
excitability.      (Grandhomme.) 


NITRANILIN,  C6H4- 
NH2NO2:  Forming 
long,  yellow  crys- 
tals.    See  Anilin. 


NITROBENZOL  Coal-tar  color  Indus-  (1)  Absorption  Poisoning  by  all  of  the  designated 
(mirbane  oil,  imita-  try  and  those  es-  takes  place,  substances  is  pretty  nearly  the 
tion    bitter-almond       tablishments  in       first     of     all,       same,  qualitatively;  quantitatively, 

oil),  C0H5NO2:  A  which  its  interme-  through  the  however,  diSerences  exist,  so  that 
colorless,  highly  re-  diate  products  are  skin,  both  the  the  larger  proportion  they  contain 
tractive  fluid,  hav-  manufactured,  as  uninjured  of  the  nitro  (NO2)  groups  the  more 
ing  an  odor  like  that  in  explosives  works,  and  e  s  p  e  -  virulent  they  are  likely  to  be.  The 
of  bitter  almonds;  perfumery  and  soap  ci  ally  the  nitrochloro  compounds  are  very 
and  all  nitro  com-  factories,  pharrna-  pathologically  rnuch  more  dangerous  than  the 
pounds  of  benzol  ceutical  laboratories,  altered  skin,  simple  nitro  compounds.  The 
and  its  homologues,       etc.  particularly       first     toxic     symptoms     may     ap- 

e.g.,    dinitrobenzol,  in    the     case       pear  within  a  few  hours  (8  to  24) 

dinitrochlorobenzol,  of    profuse       after  absorption  of  the  poison, 

nitrotoluol,      nitro-  perspira-  Acute  Poisoning. — (a)  In  mild 

phenol,    nitronaoh-  tion;    (  2  )       cases:  Malaise,  headache,  giddiness, 

thalene,    etc.     The  through     the       nausea,   loss   of   api)etite,    costive- 

most    of    the    nitro  respiratory       ness,  burning  sensation  of  the  skin 

and     chloro     com-  organs;       (3)       and  mucous  membrane, 

pounds       are       the  through     the  (b)  In  severe  cases:  A  feeling  of 

more  poisonous.  digestive    or-       anxiety,  disturbances  of  sensation, 

gans.  like  formication  on  the  legs  and  fur- 

riness  of  the  soles  of  the  feet,  ring- 
ing in  the  ears;  disturbances  of 
co-ordination  (reeling  gait,  stam- 
mering speech),  increased  excitabil- 
ity of  the  reflexes,  convulsions  and 
a  state  of  general  spasm;  later,  with 
decline  of  sensibility,  symptoms  of 
paralysis:  vomiting;  odor  of  the 
yomitus  and  of  the  exhaled  breath 
like  that  of  bitter-almond  oil;  ic- 
terus of  the  skin ;  at  first  increased, 
afterward  diminished  acti\'ity  of 
the  heart,  with  lowered  tension  of 
the  pulse;  visual  derangements 
(amblyopia,  optic  neuritis) ;  blood 
viscid,  brown  to  deep  dun  color; 
diminution^  of  the  red  corpuscles 
and  alterations  in  their  form;  in  the 
advanced  cases,  formation  of  met- 
hemoglobin.  The  course  of  se- 
vere cases  is  exceptionally  varied; 
after  intermissions,  exacerbations 
may  occur  with  a  finally  fatal  re- 
sult. Death  may  occur  also  in  con- 
nection with  deep  insensibility,  without  other  symptoms._  The  symptoms 
which  point  to  blood  changes  predominate,  in  severe  poisoning,  over  the 
nervous  symptoms. 

Subacute  and  Cheonic  PqisoNiNG.-^Icterical  skin,  which  gradually  be- 
comes cyanotic;  methemoglobin  formation;  symptoms  of  degeneration  and 
regeneration  of  the  red  blood  corpuscles;  general  debility,  anemia.  The  clin- 
ical picture  is  similar  to  that  of  pernicious  anemia.  In  the  urine  the  poi- 
soned corpuscles  are  sometimes  demonstrable,  and  finally  the  presence  of 
hematophorphyrin  and  of  albumin. 

Measures  of  relief :  Immediate  removal  from  the  workroom;  inhalation  of  oxygen;  artificial  res- 
piration; eventually  bloodletting;  stimulants,  nonalcoholic;  prohibition  of  the  use  of  alcoholic  drinks 
during  working  hours;  avoidance  of  the  same,  also,  outside  of  employment. 


HEALTH    HAZARDS    IN    OCCUPATIONS 


287 


Designation  of  tlie 
substance 


mXROG  LYCERIN, 

C3H503(N02)3  glyc- 
erin trinitrate:  An 
oily,  vaporable, 
colorless  fluid,  with- 
out odor. 


Branches  of  industry 

in  which  poisoning 

occurs 


Manufacture  of  ex- 
plosives (dynamite, 
nitro-cellulose) ;  in 
the  use  of  dynamite. 


Mode  of 

entrance 

into  the  body 


Inhalation  of 
the  vapor; 
absorption 
through  the 
uninj  ured 
skin,  mucous 
membranes, 
and  wounds 
of  the  skin. 
In  the  explo- 
sion of  dyna- 
m  i  t  e  the 
action  of  car- 
bon dioxid 
and  nitrous 
monoxid,  as 
well  as  that 
of  undecom- 
posed  nitro- 
glycerin i  8 
present. 


Symptoms  of  poisoning 


Extraordinary  toxicity,  somewhat 
like  effects  of  prus.sic  acid;  just  a 
few  drops  are  deadly,  and  even 
mere  contact  with  products  con- 
taining nitroglycerin  may  cause 
poisoning;  severe  headache,  dis- 
turbance of  the  intellect,  facile  syn- 
cope, vertigo;  burning  in  the  throat 
and  stomach;  nausea,  vomiting, 
colic;  symptoms  of  paralysis  in  the 
musclesof  the  head  and  eyes,  as  well 
as  in  the  lower  extremities;  brady- 
cardia and  retarded  respiration, 
stertorous  breathing  and  dyspnea; 
cyanosis;  coldness  of  the  extremi- 
ties; injection  of  the  conjunctiva; 
reddening  of  the  countenance. 

In  the  mixing  and  siftinp  of  dyna- 
mite: Obstinate  ulcers  under  the 
nails  and  on  the  finger  tips,  erup- 
tion on  the  plantar  aspect  of  the 
feet  and  interdigital  spaces  of  both 
hands,  with  extreme  dryness  and 
formation  of  fissures. 

Explosion  of  nitroglycerin  with 
little  gas:  Trembling,  determination 
of  blood  to  the  head,  vomiting, 
headache. 

Explosion  of_  nitroglycerin  with 
much  gas:  Vertigo,  asphyxia,  cya- 
nosis, motor  paralysis  and  loss  of 
consciousness;  intermittent,  sterto- 
rous respiration,  coldness  of  the 
skin,  small  pulse;  after  recovery  of 
consciousness,  debility,  nausea, 
vomiting,  headache,  intermittent 
pulse,  and  finally  death. 

Chronic  Poisoning. — Disturb- 
ances of  digestion,  trembling,  neu- 
ralgia. 


Special  measures  of  relief:  Absolute  avoidance  of  contact. 


NITRONAPHTHA- 
L  E  N  E.  C10H7- 
(NO2):  A  yellow, 
friable,  crystalline 
mass     of     strongly 

"  aromatic  odor.  (See 
Nitrobenzol.) 


288 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


NITROUS     GASES 

(low  degrees  of  oxi- 
dation of  nitrogen, 
which  appear  simul- 
taneously) :  Nitro- 
gen protoxid,  NO; 
nitrogen  deutoxid, 
NO2;  nitrogen  tri- 
oxid,  N2O3;  anhy- 
drous nitrous  acid 
(HNOj).  Red  fum- 
ing nitric  acid  is  a 
saturated  solution 
of  N2O4  in  crude 
NHO3.  NO  is  a 
colorless  gas  which 
under  the  influence 
of  atmospheric  oxy- 
gen, is  readily 
transformed  into 
brown  nitrogen  di- 
oxid.  Below  —20° 
C.  N2O3  is  a  blue 
fluid;  at  the  ordi- 
nary temperature  it 
separates  into  NO 
and  NO2. 


In  gaseous 
form,  through 
the  respira- 
tory organs. 


Nitrous  gases  are 
produced  by  the 
action  of  nitric 
acid  on  deoxidat- 
ing substances  of 
various  kinds,  prin- 
cipally on  metals 
(iron,  lead,  zinc, 
etc.)>  on  organic 
substances  (coal 
dust,  wood,  straw, 
paper,  textile  fab- 
rics, woolen  refuse, 
etc.)  as  well  as  many 
other  substances 

(pyrites,  sulphurous 
acid  and  its  salts, 
soda,  sediment, 
hydrochloric  acid, 
iron  chlorids,  sul- 
phate of  iron,  etc.) ; 
in  the  preparation 
of  nitric  acid,  its 
combinations  and 
salts,  among  which 
the  nitrous  salts 
also  are  to  be  in- 
cluded; metal  etch- 
ing and  metal  re- 
fining; stamp  mills 
and  mints;  galvano- 
technics;  nitrifica- 
tion in  chemical 
works  and  manu- 
factories of  explo- 
s  i  V  e  s  ;  celluloid 
manufacture;  sul- 
phuric acid  manu- 
facture: production 
of  picric  acid,  anilin 
oolors,  nitrocellu- 
lose (gun  cotton, 
collodion  cotton), 
xyloidin,  n  i  t  r  o  - 
starch,  nitro-.iute 
dynamite,  abelite, 
nitromannite,  n  i  - 
trosaccharose,  vis- 
cosin,  etc.;  nitric 
acid  manufacture 
and  storage;  prep- 
arations of  thor- 
ium and  cerium; 
bleaching  materials 
(oils,  etc.)  hat  mak- 
ing (maceration  of 
the  hair);  etching 
and  engraving  on 
copper  (etching  of 
the  plate);  dyeing 
and  printing  (fixer 
I     and  mordant). 

Special  measures  of  relief:  Immediate  removal  from  the  noxious  atmosphere;  inhalation  of  oxygen; 
finally,  bloodletting  and  infusion  of  normal  salt  solution. 


Susceptibility  to  the  effects  of 
nitrous  gases  fluctuates  consider- 
ably. Persons  who  suffer  from 
diseases  of  the  respiratory  organs 
are  especially  susceptible;  not  in- 
frequently the  continual  inhalation 
of  small  quantities,  for  many  con- 
secutive years  even,  occasions  no 
serious  disturbances  of  the  health. 
A  pale,  sallow  complexion  and 
chronic  bronchial  catarrh  may  be 
deemed,  nevertheless,  the  usual 
consequences  of  occupational  in- 
halation of  very  moderate  quan- 
tities of  nitrous  gases.  Often, 
however,  larger  quantities  of  the 
poisonous  gases  are  borne  for  hours 
together  (6  to  8  hours)  without 
discomfort;  when  suddenly,  after 
a  long  interval  without  disturb- 
ance, ominous  symptoms  appear. 

Symptoms  of  irritation  in  the  air 
passages  are  manifest,  as  a  feeling 
of  constriction  of  the  larynx,  spas- 
modic cough,  oppression  in  the 
chest,  labored  respiration,  anxiety, 
cold  perspiration  on  the  face,  pro- 
trusion of  the  eyes,  gasping  speech, 
paroxysms  of  coughing,  bluish  dis- 
coloration of  the  countenance,  cold- 
ness of  the  extremities. 

Consciousness  is  at  first  unim- 
paired, but  with  increasing  diffi- 
culty of  breathing  it  becomes 
dimmed;  injury  to  the  teeth.  The 
urine  is  scanty,  brown  in  color,  con- 
taining hemoglobin  and  albumin. 
Death  results  from  edema  of  the 
lungs.  In  very  severe  cases  met- 
hemoglobin  is  observed,  and  then 
a  general  systemic  poisoning  may 
result. 


HEALTH  HAZARDS  IN  OCCUPATIONS 


289 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


OXALIC  ACID.  C2- 
H2O4:  It  forms 
large,  pellucid 
crystals. 


Manufacture  of  ox- 
alic acid;  polish- 
ing of  metals,  es- 
pecially of  copper 
and  brass  utensils; 
used  in  dye  works, 
chemical  cleansing 
plants  (rust  and  ink 
stains) ;  straw  hat 
manufacture  and 
straw  braiding. 


In  the  form  of 
dust,  through 
the  respira- 
tory organs. 


Opalescent  or  bluish  discolorations 
(with  brittleness)  of  the  nails; 
blood  stasis  in  the  hands;  corrosive 
action  on  the  mucous  membrane 
of  the  esophagus,  of  the  stomach 
and  bowel;  weakness  of  the  heart; 
convulsions  and  spasms. 

However,    industrial    poisonings 
by  oxalic  acid  are  exceedingly  rare. 


PETROLEUM:  _  A  Production  of  oil;  re-  In  the  form  The  vapors  of  petroleum  cause  a  pro- 
mixture  of  various  fining  of  the  crude  of  vapor,  found  acute  poisoning  with  a  con- 
hydrocarbons  of  the  oil;  furniture  pol-  through  the  dition  of  inebriation;  shouting, 
methane,  ethyl,  and  ishing  by  use  of  so-  respiratory  reeling,  and  prolonged  sleep  with- 
aromatic  series.  called  polishing  oil.         organs.     As  a       out  any  recollection   of  what  has 

fluid  it  has  a  happened;  in  severe  cases,  loss  of 
direct  action  consciousness,  lividity  of  the  coun- 
on  the  skin.  tenance,    staring    look    and    con- 

tracted pupils,  almost  impercep- 
tible pulse,  asphyxia.  The  chronic 
effect  of  petroleum  vapor  causes 
numbness  and  irritation  of  the 
Schneiderian  membrane. 

In  general,  the  symptoms  of  the 
action  of  petroleum  resemble  those 
resulting  from  the  action  of  ben- 
zin.  By  reason  of  the  high  boiling 
point  of  petroleum  there  are  pro- 
duced, in  the  extraction  of  paraf- 
fin butter,  in  the  handling  of  crude 
paraffin,  in  the  emptying  of 
retorts,  and  in  the  filling  of  casks 
with  petroleum,  obstinate  inflam- 
mations of  the  hand  in  the  form 
of  acne  (nodules,  pustules,  and 
boils). 

Special  measures  of  relief :  Removal  into  the  fresh  air;  in  collapse,  a  tepid  bath  with  cold  affusions; 
subcutaneous  injections  of  camphorated  oil. 


PHENOL,  CeHsGH 
(carbolic  acid) :  A 
white  crystalline 
mass,  and  its 
homologues,  e.g., 
cresol,  lysol,  and 
their  derivatives. 


Anthracite  coal  tar 
distillation;  produc- 
tion of  picric  acid 
and  of  many  organic 
aromatic  c  o  m  - 
pounds;  used  in  dye- 
ing, calico  printing; 
manufacture  o  f 

lampblack,  in  photo- 
gen  factories;  im- 
pregnating wood 
with  tar  and  oil  of 
tar;  surgical  dress- 
ing industry. 


Action  on  the 
epidermis 
and  the  di- 
gestive tract. 


Erosion  of  the  skin,  which  by  great 
extension  may  lead  to  severe  inter- 
nal injuries;  symptoms  of  degenera- 
tion in  the  blood  and  in  the  inter- 
nal organs  (nephritis) ;  gangrene, 
icterus,  collapse. 


PHENYLHYDRA 
ZIN,  C6H5NH- 
NH2:  A  yellowish, 
oily  fluid,  shading 
into  brown,  of 
pungent  odor. 


A  by-product  in  the 
manufacture  o  f 

antipyrin  from  ani- 
lin;  manufacture  of 
organic  compounds. 


Absorption  by 
the  skin;  ac- 
tion on  the 
skin. 


Obstinate  vesicular  eruption  on  the 
skin,  with  itching  and  burning; 
diarrhea,  loss  of  appetite ;  granular 
degeneration  of  the  blood  cor- 
puscles; formation  of  methemo- 
globin;  a  sense  of  general  malaise. 


19 


290 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


PHOSGENE,  CO-  In  the  manufacture  In  the  form  Until  the  present  time  only  the  acute 
CI"  (carbon  oxy-  of  phosgene  and  its  of  vapor,  form  of  poisoning  has  been  recog- 
chiorid) :  A  color-  use  for  the  produc-  through  the  nized.  The  first  symptoms  of  ill- 
less  gas,  of  suffo-  tion  of  organic  respiratory  ness  sometimes  appear  only  after 
eating  odor.  compounds.  organs.  many  hours.  _   By  means  of  the  hy- 

drochloric acid  arising  from  the  de- 
composition of  the  gases  in  the 
lungs,  destruction  of  lung  tissue 
results,  with  difficulty  of  breath- 
ing, paralysis  of  the  lungs,  and  pul- 
monary edema.  A  fatal  outcome 
is  often  observed. 

Special  measures  of  relief:  Inhalation  of  oxygen  and  medical  attendance  immediately  after  breath- 
ing the  phosgene  gas. 


PHOSPHORUS,  P: 

A  colorless,  trans- 
parent substance; 
on  exposure  to  the 
light,  translucent 
and  of  a  yellowish, 
waxy  luster.  In 
the  air  it  is  lumin- 
ous, and  when 
heated  in  closed 
iron  crucibles  to  a 
temperature  rang- 
ing from  250°  to 
300°C.  it  is  con- 
verted into  red  or 
amorphous  phos- 
phorus, which  is  un- 
affected by  the  air. 
The  yellow  or  white 
phosphorus  is  very 
poisonous;  the  red, 
nonpoisonous. 


Extraction  of  phos-  In  the  form  As  industrial  poisoning  it  occurs  only 
phorus  from  phos-  o  f  vapor,  in  the  chronic  form,  occasioned  by 
phorites  and  cop-  through  the  the  absorption  of  very  minute  par- 
rolites,  bone-black  respiratory  tides  of  the  poison  for  a  period  of 
(refuse  of  sugar  organs;  into  months,  generally,  indeed,  of  years, 
mills) ,  bone-ash  (ref-  the  digestive  Symptoms  of  the  disease  some- 
use  of  meat  extract  canal  by  times  first  appear  long  after  relin- 
manufacture) ;  pro-  means  of  food  quishment  of  the  occupation, 
duction  of  phosphor-       contaminated  It  is   doubtful   whether   chronic 

bronze,  of  phos-  by  the  phosphorism  occurs  (that  is,  gen- 
phorus,  compounds,  fingers;  ao-  eral  systematic  poisoning  by  phos- 
igniting  agents,       tion    on    the       phorus). 

matches,      and     tar       skin.  Chronic    phosphorus     poisoning 

olors.  uniformly  affects  the  bones  of   the 

face,  beginning  with  inflammation 
and  sclerosis  of  the  bones  and  of  the 
periosteum;  then,  by  extension  of 
the  suppurative  process,  necrosis 
results.  This  most  frequently  at- 
tacks that  portion  of  the  alveolar 
process  of  the  jawbone  which  is 
least  protected  against  infection. 

Swelling  and  ulcerations  on  the 
gums  and  the  buccal  mucous  mem- 
brane, pain  even  in  the  sound 
teeth,  loosening  and  falling  out  of 
the  teeth,  infiltration  of  board  like 
hardness  occurs  in  the  soft  parts 
surrounding  the  jaw;  suppuration 
and  destruction  of  the  jawbone  (ne- 
crosis) with  numerous  fistulous 
channels  which  here  and  there  bur- 
row through  the  cheek.  Hand  in 
hand  with  the  ulcerative  processes 
go  osteoplastic  formations,  so  that, 
while  suppurative  destruction  of 
tissue  takes  place  at  one  point,  at 
another  the  formation  of  new  bone 
is  going  on.  The  under  jaw  is  more 
often  affected  than  the  upper;  here 
the  process  goes  on  insidiously 
without  formation  of  new  bone  but 
with  local  destruction  of  the  part. 
The  palatal  and  orbital  bones  may 
be  attacked  with  ulceration  and 
shrinking  of  the  eyeball.  By  ex- 
tension of  the  inflammation  along 
the  sheaths  .of  the  vessels  there  re- 
sult meningeal  inflammation  and 
cerebral  abscess. 

There  is  remarkable  brittleness 
of  the  bones,  decline  of  appetite, 
pallid  complexion,  diarrhea,  ema- 
ciation. Sometimes  there  is  amy- 
loid degeneration  of  the  abdominal 
organs.     Death  by  sepsis. 

Special  measures  of  relief:  To  the  utmost  possible  extent  the  prohibition  of  the  use  of  white  or 
yellow  phosphorus;  exclusion  of  laborers  that  have  dental  caries,  after  extraction  of  a  tooth  at  least 
two  weeks'  exclusion  from  the  employment;  change  of  occupation;  improvement  of  the  general 
health;  there  is  no  specific  medical  treatment;  in  appropriate  cases,  operative  intervention. 


HEALTH  HAZARDS  IN  OCCUPATIONS 


291 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


PHOSPHORUS 
SESQUISULPHID, 

P2S3:  A  grayish 
yellow,  odorless  and 
tasteless  substance. 


In  chemical  factories. 


Irritation  of  the  mucous  membranes, 
especially  obstinate  conjunctivitis. 
Through  the  influence  of  dust  in 
the  grinding  and  sifting  of  the  com- 
position there  appear  symptoms  of 
CSz  poisoning.  To  be  noticed  also 
is  the  danger  of  poisoning  by  sul- 
phuretted hydrogen  {See  under 
Sulphuretted  hydrogen.) 


Inhalation  of 
sulphuretted 
hydrogen  in 
the  fusion  of 
phosphorus 
and  sulphur 
as  well  as  in 
the  drawing 
off  of  the 
molten  mass 
from  the  ket- 
tles; dust  in 
the  grinding 
and  sifting  of 
the  paste;  bi- 
carburet  of 
sulphur  va- 
pors in  the 
extraction  of 
yellow  phos- 
phorus and 
regeneration 
of  CS2. 

Special   measures   of  relief:  Prevention  of  the  contamination  of  phosphorus  sesquisulphid  with 
yellow  phosphorus;  precautions  against  injury  from  the  effects  of  sulphuretted  hydrogen. 


PHOSPHURETED 
HYDROGEN, 

PH3:  A  colorless 
gas  of  nauseating 
odor. 


In  the  extraction  of 
phosphorus;  in  the 
preparation  of  red 
phosphorus  and 

the  sesquisulphid 
of  phosphorus;  in 
the  reduction  of 
iron  silicate  con- 
taining phosphorus 
by  the  action 
of  moisture;  in  the 
production  of  acety- 
lene with  calcium 
carbid  that  contains 
an  admixture  of  cal- 
cium phosphate. 


In  the  form  of 
gas,  through 
the  respira- 
tory organs. 


An  anxious,  oppressed  feeling  in  the 
chest,  changing  to  a  burning,  lan- 
cinating pain;  affections  of  the 
head,  vertigo,  tinnitus  aurium; 
general  debility;  loss  of  appetite; 
great  thrist.  Death  occurs  with- 
out convulsions,  through  the  effect 
of  the  poison  on  the  blood. 


PICRIC  ACID,  C6H2 
(OH)(N02)3:  Tri- 
nitrophenol  in  a 
pure  state  forms 
pale  yellow,  bitter 
tasting,  foliate,  me- 
tallic crystals. 


Chemical  works,  dye- 
houses;  manufac- 
ture of  explosives 
and  powder  (lydd- 
ite, melinite) ;  pro- 
jectile factories,  fil- 
ling shops. 


In  the  form  of 
dust,  through 
the  respira- 
t  o  r  y  pa  s  - 
sages ;  direct 
action  on  the 
skin. 


Poisonings  with  picric  acid  are  rare; 
when  they  occur  there  are  itching, 
inflarnmation  of  the  skin,  vesicular 
eruption,  yellow  pigmentation  of 
the  epidermis  and  of  the  conjunc- 
tiva, inflammation  of  the  buccal 
niucous  membrane,  bitter  taste, 
disturbances  of  digestion,  epigas- 
tric pain,  nausea,  vertigo,  diarrhea, 
and  jaundice;  picric  acid  decom- 
poses the  constituents  of  the  blood. 
By  the  penetration  of  dust  into 
the  nostrils,  sneezing  and  nasal 
catarrh  are  occasioned. 


PYRIDIN,  CsHsN: 
A  colorless  fluid  of 
pungent  and  char- 
acteristic odor.  Its 
homologues,  py- 
ridin  bases. 


In  its  manufacture 
out  of  coal  tar  and 
bone  tar;  in  the  use 
of  denaturing  spir- 
its (shops  for  wood- 
working, gilding, 
and  hat  manufac- 
ture) . 


In  the  form 
of  vapor, 
through  the 
respiratory 
organs.  In  a 
fluid  state  it 
acts  on  the 
skin  of  the 
hands  and 
arms. 


Catarrh  of  the  mucous  membranes; 
hoarseness,  irritation,  and  choking 
sensation  in  the  throat;  headache, 
vertigo,  flaccidity  and  trembling  of 
the  extremities;  difiiculty  of 
breathing  and  clonic  convulsions; 
eczema  of  the  hands. 

Industrial  poisoning  by  pj-ridin 
is  very  rare. 


SULPHUR  CHLO- 
RID,  SeCh:  A 
thickish  fluid,  of 
brownish  color  and 
suffocating  odor, 
fuming  on  exposure 
to  the  "air. 


Solvent  for  sulphur 
and  fats;  caout- 
chouc and  patent 
rubber  industry. 


In  the  form 
of  vapor, 
through  the 
respiratory 
organs. 


In  contact  with  water  and  atmos- 
pheric moisture,  it  is  resolved  into 
hydrochloric  acid  vapor.  The 
vapor  of  sulphur  chlorid  is  suffo- 
cating; if  ingested,  it  excites  vomit- 
ing. 


Special  measures  of  relief :  Wearing  of  rubber  gloves;  instant  removal  of  the  patient  from  the 
poisonous  atmosphere. 


292 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Designation  of  the 
substance 


Branches  of  industry 

in  w+iich  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


SULPHUR  DIOXID, 
SULPHUROUS 
ACID,  (H2SO3):  Its 
anhydrid  is  SO2,  in 
the  form  of  gas; 
condensed,  it  be- 
comes fluid.  The 
gas  is  of  pungent 
odor  and  suffocat- 
ing effect. 


Roasling  of  sulphur- 
bearing  ores;  brick 
works,    ceramic    in- 

-  dustry;  manufacture 
of  sulphuric  acid, 
of  ultramarine;  ex- 
traction of  bones, 
manufacture  of  glue 
and  gelatine  from 
bones;  disinfection; 
refining  of  petro- 
leum; manufacture 
of  candles;  bleach- 
ing of  wax,  silk,  and 
wool;  chromium 
tanning  (two-yat 
process) ;  bleaching 
of  straw  hats  and 
bristles;  preserving 
wine  and  fruits; 
fumigating  hops  and 
casks  with  sulphur; 
ice  machines;  heat- 
ing plants  (burning  of 
pynte-bearing  coal). 


In  the  form  of 
gas,  through 
the  respira- 
tory organs. 


In  moderate  concentration  sulphur- 
ous acid  is  borne  without  inconven- 
ience or  injury ;  persons  accustomed 
to  the  gas  bear  very  well  a  propor- 
tion of  0.003  to  0.004  per  cent,  of 
SO2  in  the  air. 

Susceptible  persons,  at  the  be- 
ginning of  their  employment  in  an 
atmosphere  containing  sulphurous 
acid,  manifest  a  transient  irritation 
of  the  mucous  membrane  of  the 
respiratory  organs  and  of  the  eyes. 
In  its  severe  action  there  is  spas- 
modic cough  with  secretion  of 
tenacious,  often  blood-tinged, 
mucus.  The  protracted  effect  of 
a  high  degree  of  concentration  is 
livid  discoloration  of  the  mucous 
membranes,  _  bronchial  catarrh, 
croupous  angina  of  the  bronchi  and 
their  branches,  and  inflammatory 
areas  in  the  lungs;  disturbances  of 
digestion. 


Svecial  measures  of  relief:  Removal  from  the  noxious  atmosphere;  admission  of  fresh  air;  artificial 
respiration;  infusion  of  weak  alkaline  solutions  (0.05  to  0.1  per  cent,  liquor  natrii  caustici  [solution 
of  caustic  soda]) . 


SULPHURETED     Blast  furnace  plants.     In  the  form  of 

HYDROGEN,       or       in    granulating    the       gas,    through 

HYDRIC       SUL-       slag;    distillation    of       the      respira- 

PHID,  H2S:  A  col-       sulphur       waters;       tory     organs, 

orless    gas,    having       ultramarine     works:       as    pure    hy-^ 

the    fetid    odor    of       Leblanc     soda     and       dric     sulphid 

rotten  eggs.  chemical     factories;       gas;      often 

in      the       manufac-       found  in   ad- 
ture     of     the     com-       mixture  with 
pounds    of    sulphur       other       gases 
and       phosphorus;       (with  COs,  N 
sulphur        metals       NH4,        and 
(manufacture       and       carburetted 
use) ;       sulphid       of       hydrogen) ;  di 
soda     and     sulphid       rect  action  on 
of      barium      indus-       the    conjunc- 
try        (manufacture       tiva. 
of      sulphid      colors 
and      dyeing      with 
these) ;    the    extrac- 
tion     of       cellulose 
(straw    and    wood) ; 
in     the     waste     wa- 
ters    of     industries 
which      make      use 
of       organic     _  sub- 
stances;       sedimen- 
tation      tanks       of 
sugar     works ;     pre- 
cipitation    of     soda 
residua      containing 
calcium  sulphid; 

work  in  sewers, 
latrines,  and  dung 
pits;  illuminating 
gas  plants;  flax 
retteries;    tanneries. 

Svecial  measures  of  relief:  Before  emptying  of  dung  pits  a,nd  the  like,  their  contents  should 
be  thoroughly  mixed  with  iron  sulphate  (.5  kg.  pro  1  cbm.);  the  emptying  should  be  effected  by 
mechanical  apparatus;  safety  ropes  to  be  attached  to  the  workmen;  prompt  hoisting  out  of  the 
unconscious  workmen;  removal  of  the  soiled  clothing;  artificial  respiration;  administration  of 
oxygen;  hypodermics  of  ether  or  camphor. 


In  the  less  violent  cases  there  are 
gastric  distress,  _  nausea,  fetid 
eructations,  irritation  and  inflam- 
mation of  the  conjunctiva;  rarely, 
erosion  of  the  cornea,  formation  of 
vesicles  on  the  lips,  irritating 
cough,  headache,  and  a  sensation  of 
giddiness.  In  long  continued  in- 
halation convulsions  and  paralyses 
occur. 

In  severe  cases  there  are  contrac- 
tion of  the  pupils,  slowing  of  the 
pulse,  Cheyne-Stokes  respiration, 
nystagmus,  trismus,  and  tetanus. 

With  a  very  high  proportion  of 
sulphuretted  hydrogen  in  the  air 
a  man  suddenly  falls,  becomes  un- 
conscious, and  dies  without  con- 
vulsions (apoplectic  form). 

Chronic  Poisoning. — Conjunc- 
tival catarrh;  a  sense  of  pressure 
in  the  head  and  on  the  chest; 
headache,  debility,  vertigo,  nausea, 
disturbances  of  digestion;  sallow 
complexion  and  emaciation;  slow- 
ing of  the  pulse;  tendency  to  the 
formation  of  boils. 


HEALTH  HAZARDS  IN  OCCUPATIONS 


293 


Designation  of  the 
substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance 

into  the  body 


Symptoms  of  poisoning 


SULPHURIC  ACID, 

H2SO4:  A  colorless, 
odorless,  thick,  oily 
fluid. 


Manufacture  of  sul- 
phuric acid;  accu- 
mulator factories 
(mold  and  charg- 
ing rooms) ;  burn- 
ishing of  iron, 
steel,  etc.;  textile 
industry,  hat  fac- 
tories; petroleum 
distillation;  facto- 
ries for  the  manu- 
facture of  pow- 
dered fertilizers. 


In  the  form 
of  vapor, 
through  the 
respiratory 
organs. 


Inflammatory  diseases  of  the  res- 
piratory organs  (acute  and  chronic 
catarrh),  inflammation  of  the 
lungs;  anorexia;  decalcification  of 
the  bones  (according  to  Lewin) ; 
injury  to  the  teeth  through  soften- 
ing of  the  dentin. 

As  a  result  of  the  bespattering 
of  the  skin  with  concentrated 
H2SO4  there  is  severe  pain,  a 
whitish  discoloration  of  the  skin, 
becoming  brownish,  with  redden- 
ing and  swelling  of  the  surround- 
ing tissues;  in  cases  of  extensive 
scalds  there  are,  ultimately,  de- 
composition of  the  blood,  forma- 
tion of  ulcers  of  the  duodenum, 
somnolence,  and  even  death. 


TAR :  A  product  ob- 
tained by  dry  distil- 
lation, particularly 
of  anthracite  coal 
and  lignite. 


Manufacture  of  illu- 
minating gas;  coke 
ovens;  tar  works; 
tar  product  facto- 
ries; plants  for 
wood  preserving; 
manufacture  o  f 

roofing  paper;  use 
for  concrete  pav- 
ing; painting  of 
metals;  as  a_  fuel; 
briquet  factories. 


It  acts  on  the 
skin;  in  the 
form  of 
vapor,  on  the 
respiratory 
organs. 


Tar  itch  under  the  form  of  diffuse 
acne,  eczema  or  psoriasis,  primarily 
on  the  upper  extremities,  later, 
also,  on  the  other  parts  of  the 
body;  not  infrequently  on  the 
irritated  portions  of  the  skin  there 
appear  cancroid  ulcers,  especially 
of  the  scrotum  (among  chimney 
sweepers,  paraffin  and  soot  workers 
and  briquet  makers). 

Together  with  the  effect  on  the 
greater  portion  of  the  skin,  there 
are  also  general  symptoms:  Loss 
of  appetite,  nausea,  diarrhea,  head- 
ache, numbness,  vertigo,  besides 
disturbances  of  the  urinary  blad- 
der (ischuria,  strangury),  also 
albuminuria  and  edema. 


TURPENTINE 
OIL:  A  mixture  of 
various  terebinthin 
hydrocarbons,  Cicr 
H16,  differing  in 
odor  and  in  com- 
position according 
to  the  botanical 
species  from  which 
they  are  severally 
derived. 


Manufacture  of  var- 
nish, cement,  lac- 
quer, sealing  wax, 
colors  ;  tapestry 
printing;  trade  of 
decorator,  lacquerer, 
and  house  painter; 
as  a  cleansing  agent 
in  various  industries. 


In  the  form  of 
vapor,  it  acts 
upon  the  mu- 
c  o  u  s  mem- 
branes; in  a 
fluid  state,  it 
acts  on  the 
epidermis. 


Irritation  of  the  mucous  membrane 
of  the  eyes,  of  the  nose  (coryza), 
and  of  the  upper  air  passages  (hem- 
ming, cough,  bronchial  inflamma- 
tion); salivation;  besides,  there  are 
insensitiveness,  giddiness,  head- 
ache. 

Prolonged  action  of  the  oil  causes 
irritation  of  the  kidneys,  and  then 
these  organs  excrete  urine  having 
the  odor  of  violets. 

Severe  irritation  of  the  skin  is 
excited,  especially  by  the  so-called 
pine  oil  (Russian  oil  of  turpentine). 


294 


INDUSTRIAL    MEDICINE    AND    SURGERY 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR 


Designation  of  industrial  poison 

Nitrous  gases 

See  Batteries,  storage    • 

Lead 

Phosphuretted  hydrogen 


(From    Diseases   of    Occupation  and  Vocational  Hygiene,    Kober  and  Hanson) 

Branches  o/  industry  in  which  poisoning 
may  occur 

Abelite,  manufacture  of 

Accumulator,  electrical  works 

Acetate  of  lead,  manufacture  of 

Acetylene  production  (if  calcium 
carbid  contains  admixture  of  cal- 
cium phosphate) 

Acids,  commercial  manufacture  of 

Acid,  hydrochloric,  manufacture  of 

Acid,  hydrofluoric,  manufacture  of 

Acid,  muriatic,  manufacture  of 

Acid,  picric,  manufacture  of 

Acid,  stearic,  manufacture  of 

Acid,  sulphuric,  manufacture  of 

Acid,  valeric,  manufacture  of 

Air  pollution 

Alcohol,  denatured 

Alkaloids,  manufacture  of 

Amber  workers 

Amalgam 

Ammonia  salts,  manufacture  of 

Ammunition,  manufacture  of 


Amid  compounds  of  benzol,  etc. 

Amyl  nitrite,  manufacture  of 

Anatomical  preparations 

AniUn  color  dye  factories:  Anilin 
orange,  aurantia,  saffron  yellow, 
Manchester  yellow,  Meldola  dyes, 
corvulin,  Bismarck  blue,  indulin, 
fast  black 

Antimony  alloys,  and  extraction  of 

Antiseptic  dressing,  manufacture  of 

Antipyrin,  manufacture  of 

Arsenic  acid,  manufacture  of 

Arsenic  mining 

Arsenical  ores,  smelting 

Artificial  flowers  and  leaves 

Artificial  ice  and  cold  storage 

Asphalt,  testing 

Aurantia  dyes 

Automobilists 

Babbitting  metal,  and  solder 

Bakers  and  confectioners 

Balloon  filling  with  impure  hydrogen 
gas 

Barium  sulphid,  manufacture  of 

Barometers,  manufacture  of 


Arsenic 

Hydrochloric  acid 

Hydrofluoric  acid 

Hydrochloric  acid 

Picric  acid 

Acrolein 

Nitrous  gases,  sulphur  dioxid 

Amyl  alcohol 

Carbon  dioxid,  carbon  monoxid 

Benzol,  methyl  alcohol,  pyridin 

Benzol 

Lead  | 

Mercury  j 

Ammonia  \ 

Acrolein,  antimony,  lead  (see  also  "Ex- 
plosives") 

Anilin 

Amyl  alcohol 

Formaldehyd,  phenol 

AniUn,  arseniuretted  hydrogen,  antimony, 
hydrochloric  acid,  methyl bromid,  nitro- 
benzol,  nitrous  gases 


Antimony,  lead  \ 

Mercury,  phenol 

Benzin,  phenylhydrazin 

Arsenic,  arseniuretted  hydrogen 

Arsenic 

Arsenic 

Arsenic,  lead 

Ammonia 

Carbon  disulphid 

Anilin  dyestuffs 

Carbon  monoxid,  benzin 

Lead 

Carbon  dioxid,  carbon  monoxid 

Arseniuretted  hydrogen 

Sulphuretted  hydrogen 
Mercury 


HEALTH  HAZARDS  IN  OCCUPATIONS 


295 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR  {Continued) 


Branches  of  industry  in  which  poisoning 
may  occur 

Batteries,  storage,  dry,  manufacture  of 


Batteries,  storage,  wet,  manufacture  of 

Beet  sugar,  manufacture  of 

Benzin  plants 

Benzol 

Bicycles,  manufacture  of 

Bismarck  blue,  manufacture  of 

Bismuth,  manufacture  of 

Black  anilin  colors 

Blacksmiths 

Blast  furnace  workers 


Bleacheries 

Bleaching  agents,  manufacture  of 

Bleaching  agents,  for  bristles,  cane, 
silk,  straw  hats,  wax  and  wool 

Bleaching  agents  for  cotton,  linen 
and  paper 

Bleaching  agents  for  cane  and  extrac- 
tion of  its  silicates 

Bleaching  agents  for  fats,  oil  and  wax 

Bone  ash,  refuse  of  meat  extract 

Bone-black,  refuse  of  sugar  refineries 

Bone-black,  manufacture  of 

Bone,  extraction  of 

Bone,  rendering  plants 

Bone  tar,  manufacture  of 

Bookbinders 

Boot  and  shoe  industry 

Bottle  caps  and  capsules 

Box  and  card  factories 

Brasiers 

■* 
Brass  etching 

Brass  instruments,  musical 

Brass  foundries 


Brass  polishing 

Brass  lacquer 

Breweries,  fermentation  rooms 

Breweries,    fumigation    of   vats,    and 

disinfection 
Breweries,  shellacing  casks 
Brick  kilns,  brick  and  tile  makers 


Designation  of  industrial  poison 

Benzol,  creosote,  hydrochloric  acid, 
sulphuric  acid,  lead,  mercury,  pitch, 
zinc  chlorid 

Chromium  compounds 

Ammonia,  sulphuretted  hydrogen 

Benzin 

Benzol 

Amyl  acetate 

Anilin  dyestuffs 

Arsenic 

Anilin  dyestuffs 

Acrolein,  carbon  monoxid,  cyanogen 
compounds 

Carbon  monoxid,  cyanogen  compounds, 
lead  fumes,  if  lead  is  present  in  iron 
ore,  sulphur  dioxid,  sulphuretted  hy- 
drogen (in  granulating  slag) 

Chlorin,  sulphur  dioxid 

Nitrous  gases 

Sulphur  dioxid,  chlorid  of  lime 


Hydrofluoric  acid 

Chlorin,  chromium  compounds 

Phosphorus 

Phosphorus 

Ammonia,  phosphorus 

Sulphur  dioxid 

Acrolein,  benzin 

Pyridin 

Carbon  monoxid,  methyl  alcohol 

Benzin,  methyl  alcohol,  lead,  mercury 

Lead 

Arsenic,  chrome  and  lead  compounds 

Carbon  monoxid 

Arsenic  chlorid 

Lead 

Antimony,  benzin,  carbon  dioxid,  carbon 

monoxid,    lead,    phosphorus,    sulphur 

dioxid,  zinc  fumes 
Lead,  oxahc  acid,  sulphuric  acid 
Amyl  acetate,  methyl  alcohol 
Carbon  dioxid 
Sulphur  dioxid,  zinc  oxid 

Methyl  alcohol 

Carbon  dioxid,  carbon  monoxid,  sulphur 
dioxid,  lead  glaze 


296 


INDUSTRIAL   MEDICINE    AND    SURGERY 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR  (Continued) 


Branches  of  industry  in  which  poisoning 
may  occur 

Briquet  factories  for  fuel- 
Britannia  metal 
Bronze  workers 

Bronzing  with  nitrate  of  mercury- 
Brown  mineral  mills 
Brunswick  green 
Brush  makers 

Bullets,  dipping 

Bullets,  manufacture  of 

Burnishing  of  iron  and  steel 

Cable  wire,  manufacture  of 

Cabinet  makers 

Caoutchouc  solvent  and  refining  of 

Caisson  work 
Calcining  dolomite,  etc. 
Calico  printing 


Candles,  manufacture  of 
Cane  factories 


Canning  industry- 
Carbolic  acid 
Carbonated  waters 
Carbon  chlorid,  manufacture  of 
Carbon  sulphurate,  manufacture  of 
Carbonizing  of  materials 
Carpet  cleaning 
Carpet  dye 
Cassel  green 
Celluloid  manufacture 


Cellulose,  extraction  from  straw  and 

wood 
Cements 
Ceramic  industry 

Cerium,  preparation  of 
Chair  factories,  polishing 

Chalk,  colored 

Charcoal  burning 

Chemical  cleansing  establishments 


Designation  of  industrial  poison 

Tar 

Antimony 

Antimony,  lead,  zinc,  arsenic,  acids, 

phosphorus 
Mercury 
Manganese 
Arsenic 
Anthrax,   lead,   methjd  alcohol,  tar  (see 

also  bleaching) 
Acrolein 
Antimony,  lead 
Antimony,  sulphuric  acid 
Carbon  disulphid,  lead 
Anilin  stains,  chrome  lead  stains 
Benzol,  carbon  disulphid,  sulphur 

chlorid 
Carbon  dioxid 

Carbon  dioxid,  carbon  monoxid 
AniUn,  chromium,  cyanogen  and  chlorin 

compounds,    hydrochloric    acid,    lead, 

methyl   alcohol,   phenol,   antimony, 

arsenic,  carbon  monoxid 
Sulphur  dioxid 
Anilin    stains,    chlorin,   chlorid   of  lime, 

hydrofluoric    acid,    methyl   alcohol, 

sulphur  dioxid 
Carbon  monoxid,  lead,  acid  fumes, 

sulphur  dioxid 
Phenol 

Carbon  dioxid 
Carbon  disulphid 
Carbon  disulphid 

Acid  fumes  and  arseniuretted  hydrogen 
Benzin 
Arsenic 
Arsenic 
Acetaldehyd,    anilin    and    lead    colors, 

cyanogen  compounds,  methyl  alcohol, 

nitrous   gases,  sulphuretted   hydrogen. 
Nitrous  gases,  sulphuretted  hydrogen 

Turpentine,  benzin 
Hydrofluoric  acid,  lead,  sulphur 

dioxid  (see  also  Potteries) 
Nitrous  gases 
Methyl    alcohol,     petroleum     (see    also 

Rattan  Industry) 
Arsenic 

Carbon  monoxid 
Benzin,  benzol 


HEALTH  HAZARDS  IN  OCCUPATIONS 


297 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR  {Cmdinued) 

Designation  of  induntrial  poison 

Oxalic  acid 


Branches  of  industry  in  which  poisoning 
may  occur 


Chemical    cleansing    removal    of    ink 

and  rust  stains 
Chemical  industry 


Chlorid  of  lead 

Chlorid  of  lime,  manufacture  of 

Chlorinating  process 

Chlorin,  organic  products 

Chloroform  manufacture 

Chromate  of  lead 

Chromate  tanning 

Chromium  colors  and  preparations 

Chromo-lithography 

Christmas  ornaments,  manufacture  of 

Ghrysoidin  fast  black,  manufacture 

Church  crosses,  gilding 

Cinnabar 

Cleaning,  dry 

Coal  mines 

Coal  oil 

Coal-tar  anthracite  distillation 

Coal-tar  color  industry 

Cochineal 

Coke  ovens 

Collodion  cotton 

Commercial  acids,  impure 

Colors,    manufacture    of    for  paints, 

etc. 
Colored  chalk 
Colored  lights 
Colored  paper 
Colored  pencils 
Combs,  horn-celluloid 

Compositors 

Concrete  paving 

Coopers 

Copper  plate  etching  and  engraving 

Copper  polishing 

Copper  smelting 

Copper  workers 


Ammonia,  anilin,  carbon  disulphid, 
chlorin,  cyanogen  compounds,  hydro- 
chloric acid,  methyl  compounds, 
nitrous  gases,  nitrobenzol,  phosphorus 
sesquisulphid,  picric  acid,  sulphur 
dioxid,  carbon  monoxid,  etc. 

Lead 

Chlorin,  arseniuretted  hydrogen 

Chlorin 

Chlorin 

Chlorid  of  lime 

Chromium,  lead 

Chromium  compounds 

Chromium  compounds 

Arsenic,  brass,  chromium,  lead,  nitrous 
gases  in  etching,  turpentine 

Arsenic 

Anilin  dyestuffs 

Mercury 

Mercury 

Benzin,  benzol 

Carbon  dioxid,  carbon  monoxid  (see 
mining) 

Petroleum 

Phenol,  pyridin,  tar 

Anilin,  formaldehyd,  methyl  alcohol, 
nitro-benzol,  nitrous  gases 

Arsenic 

Ammonia,  carbon  monoxid,  tar 

Nitrous  gases 

Arsenic 

Benzin,  benzol,  chromium  compounds, 
arsenic,     lead,     mercury,     turpentine 

Arsenic 

Arsenic,  antimony 

Arsenic,  chromium,  lead  compounds 

Anilin  dyestuffs 

Acetaldehyd,  acid  fumes,  anilin,  lead 
colors  (see  also  Celluloid) 

Lead,  antimony,  arsenic,  benzin 

Tar 

Methyl  alcohol  shellac 

Nitrous  gases 

Oxalic  acid 

Arsenic,  carbon  monoxid,  sulphur  dioxid 

Arseniuretted  hydrogen,  lead,  nitric  and 
sulphuric  acid  fumes 


298 


INDUSTRIAL    MEDICINE    AND    SURGERY 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR  {Continued) 


Branches  of  industry  in  which  poisoning 
may  occur 

Corvulin  dye 

Cowper  apparatus 

Creasote,  cresol 

Cumol 

Cutlery  industry 

Decorators  and  painters 


Decomposition  gases 

Denaturing  of  spirits 

Dentists 

Deoxidating  processes 

Diamond     cutting     and     setting     of 

precious  stones 
Dinitrobenzol,  manufacture  of 
Dinitrochlorobenzol,  manufacture  of 
Dinitro-compounds,  manufacture  of 
Dip  for  scabby  sheep 
Disinfection 


Distilleries 

Dolomite  calcining 

Drying  processes  by  means  of  open 

fires 
Dung  pits 
Dyes,  antiseptic 
Dyes,  organic,  manufacture  of 
Dyestuffs 

Dyeing      and      printing,     fixer     and 

mordant 
Dyeing  and  dye  works 


Dynamite,  manufacture  of 
Electrical  accumulator  works 
Electric  lamps,  manufacture  of 
Electric  lamps,  incandescent  wire 
Electric  line  workers 
Electric  meters 
Electroplating 


Designation  of  industrial  poison 

Anilin  dyestuffs 

Carbon  monoxid 

Phenol 

Benzol 

Carbon  monoxid,  acid  fumes,  lead  (see 
also  Brass,  Tempering,  Tinning) 

Arsenic,  benzin,  chromium  compounds, 
lead,  mercury,  methyl  alcohol  turpen- 
tine 

Ammonia,  carbon  dioxid,  sulphuretted 
hydrogen 

Methyl  alcohol,  pyridin 

Mercury 

Nitrous  gages 

Lead,  carbon  monoxid 

Nitrobenzol 

Nitrobenzol 

Nitrobenzol 

Arsenic 

Carbon  disulphid,  chlorin,  chlorid  of  lime, 

cyanogen     compounds,     formaldehyd, 

mercury    bichlorid,     phenol,     sulphur 

dioxid 
Carbon    dioxid,  sulphuretted  hydrogen, 

sulphur  dioxid 
Carbon  dioxid,  carbon  monoxid 
Carbon  monoxid 

Ammonia,  sulphuretted  hydrogen 

Mercury 

Acridin 

Ammonia,     chlorid     of    lime     (see    also 

Anilin  Dyestuffs) 
Nitrous  gases 

Antimony,  arsenic,  anilin  dyestuffs,  ben- 
zol, chromium  compounds,  cyanogen 
compounds,  hydrofluoric  acid,  phenol, 
oxalic  acid,  picric  acid,  sulphuretted 
hydrogen  (dyeing  with  sulphid  colors), 
ammonia,  lead,  methyl  alcohol 

Nitrous  gases,  nitroglycerin 

See  Batteries 

Lead,  mercury 

Amyl  acetate 

Carbon  monoxid,  solder 

Mercury,  lead  (see  also  Brass  Industry) 

Cyanogen  compounds 


HEALTH  HAZARDS  IN  OCCUPATIONS 


299 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR  (Continued) 


Branches  of  industry  in  which  poisoning 
may  occur 

Electrotyping 

Emery  wheels,  babbitting  of    . 
EaameUing  works 

Engraving,  steel 
Essences,  fruit,  artificial 
Etching  on  brass 
Etching  on  metals 

Ether,  methyl 
Ethyl  violet 
Extraction  of  antimony 
Extraction  of  bone 
Extraction  of  gold  and  silver 
Explosives,  manufacture  of 

Farmers 

Fats,  bleaching  of 
Fats,  extractions  of 
Fats,  solvents 

Faucets,  brass,  polishing 
Feathers,  ornamental 
Fermentation  rooms 
Felt  hat  industry 


Ferrosilicon 

Fertilizers,  artificial  manufacture  of 


File  cutting 
Fireworks 

Firearms,  manufacture  of 
Firemen 

Flasks,  manufacture  of 
Flax  retteries 
Flowers,  artificial 
Foundries,  iron 
Fluoric  acid 
Fluorides,  extraction  of 
Fruit  essences,  manufacture  of 
Fruit,  dried,  preservation 
Fuel  briquet  factories 
Fumigation  casks,  hops,  fruit 


Desiynation  of  industrial  poison 

Antimony,        arsenic,        lead,        carbon 

monoxid 
Lead 
Hydrochloric  acid,  lead,  benzin,  carbon 

monoxid 
Mercury 
Amyl  alcohol 

Arsenic  chlorid,  nitrous  gases 
Arseniuretted  hydrogen,  mercury,  nitrous 

fumes,  chlorin,  phosphoric  acid 
Dimethyl  sulphate 
AniUn  dyestuffs 
Antimony 
Sulphur  dioxid 

Cyanogen  compounds,  mercury 
Anilin  dyestuffs,  mercury,  nitrous  gases, 
nitro-benzol,  nitroglycerin,  picric  acid 
Carbon    dioxid    in    silos    (see    also  in- 
secticides) 
Chromium  compounds 
Benzin,  benzol,  acrolein,  carbon  disulphid 
Benzol,  benzin,  carbon  disulphid,  sulphur 

chlorid 
Lead 
Benzin 

Carbon  dioxid^ 

Mercury,  methyl  alcohol,  nitrous  gases, 
sulphuric    acid,     nitric    acid,     arsenic 
dyestuffs,  carbon  monoxid 
Arseniuretted  and  phosphuretted  hydro- 
gen 
Hydrochloric  acid,  hydrofluoric  acid,  sul- 
phuric   acid,    sulphuretted    hydrogen, 
benzin 
Lead 

Antimony,  arsenic,  carbon  monoxid,  phos- 
phorus 
Antimony,  carbon  monoxid,  nitrous  gases 
Benzin,    carbon    monoxid,    nitrous    and 

other  acid  fumes 
Lead 

Sulphuretted  hydrogen 
Arsenic,  lead 

Carbon  monoxid,  sulphuric  acid 
Hydrofluoric  acid 
Hydrofluoric  acid 
Amyl  alcohol 
Sulphur  dioxid 
Tar 
Sulphur  dioxid 


300 


INDUSTRIAL    MEDICINE    AND    SURGEBT 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR  {Continued) 

Branches  of  industry  in  which  poisoning  Designation  of  industrial  poison 

may  occur 

Furnace  gases  -  Carbon    monoxid,    sulphur    dioxid    (see 

also  Blast  Furnaces) 

Anilin,  arsenic,  chrome  stains,  lead,  methyl 
alcohol,  petroleum,  phenol,  turpentine 

Lead  for  dyeing;  mercury  and  nitrous 
gases  for  rabbit  fur,  arsenic,  anthrax 

Cyanogen  compounds 

Nitrous  gases 

Ammonia,  arseniuretted  hydrogen,  hydro- 
chloric and  sulphuric  acids,  zinc 

Benzin,  carbon  monoxid 

Benzin 

See  Insecticides 

Anilin  and  arsenic  dyes,  carbon  mon- 
oxid from  ironing  stoves,  lead  from 
weighted  silk 

Ammonia,  carbon  monoxid,  cyanogen 
compounds,  tar 

Arseniuretted  hydrogen,  lead,  nitrous 
gases 

Carbon  monoxid 

Carbon  monoxid,  cyanogen  compounds 

Benzin 

Sulphur  dioxid 

Mercury 

Hydrofluoric  acid 

Arsenic,  hydrofluoric  acid,  hydrochloric 
acid,  chromium  compounds,  carbon 
monoxid,  lead,  manganese,  phenol 
(see  also  Painter) 

Lead 

Lead 

Anthrax,  acids,  anilin,  chrome  and  lead 
compounds 

Benzin 

Arsenic  from  impure  sulphuric  acid 

Sulphur  dioxid,  chlorid  of  lime 

Nitroglycerin 

Cyanogen  compounds,  mercury 

Cyanogen  compounds 

Benzin,  benzene,  carbon  disulphid 

Carbon  disulphid 

Nitroglycerin,  nitrous  gases 

Antimony,  cyanogen  compounds,  carbon 
monoxid 

Anthrax 

Acrolein,  cyanogen  compounds  and  lead 

Mercury,  methyl  alcohol,  nitrous  gases, 
sulphuric  acid,  arsenic,  dyestuffs,  car- 
bon monoxid 


Furniture     factories,     staining     and 

polishing 
Furriers 

Galvano-plasty 
Galvano-techniques 
Galvanizing  with  zinc  or  tin 

Garage  workers 
Garbage  fat  extraction 
Gardeners 
Garment  workers 


Gas  plants 

Gas  and  steam  fitters 

Gas  machines 

Gas  purification 

Gasolin 

Gelatin  manufacture 

Gilding  and  silvering 

Glass  etching 

Glass  factories 


Glass  polishing 

Glaze  mixing  and  dipping 

Glove  and  mitten  manufacture 

Glove  cleaning 
Glucose,  manufacture  of 
Glue,  manufacture  of 
Glycerin,  trinitrate 
Gold,  extraction  of 
Gold  plating 
Grease  removal 
Gums,  solvent  for 
Gun  cotton 
Gunsmiths 

Hair  industry 

Hardening  and  tempering  steel  mag- 
nets, piano  wire,  springs,  files,  etc. 
Hat,  felt,  factory 


HEALTH  HAZARDS  IN  OCCUPATIONS 


301 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR  {Continued) 

Branches  of  industry  in  which  poisoning  Designalion  of  industrial  poison 

may  occur 

Hat,  straw,  factory 

Heating  and  power  plants 
Hectograph  composition 
Hides  and  skins 

Hittorf  tubes 
Hydrochloric  acid 
Hydrogen  gas 
House  painting 

Ice  machines 

Igniting  agents 

Illuminating  gas,  manufacture  of 


Imitation  bitter-almond  oil 
Imitation  silk  factories 

Imperial  yellow  dye,  manufacture  of 
Impregnated  wood 
Incandescent  electric  Ught 

India  rubber  industry 


Indian  white  fire 

Indulin  dye,  manufacture  of 

Ink  stains,  removal  of 

Insecticides,  manufacture  and  use  of 

Insulated  wire,  manufacture  of 

lodin,  manufacture  of 

Iron  chlorid,  sulphate,  manufacture 

Iron,  deoxidation  of 

Iron,  galvanizing  with  zinc  or  tin 

Iron  silicate,  impure,  decomposition 

of 
Iron  sulphate,  manufacture  of 
Ironing 

Iron  sanitary  ware 
Iron  and  steel  workers 

Jewelry,  manufacture  of 
Kaiser  green 


Sulphur   dioxid,    methyl   alcohol,    oxalic 

acid 
Carbon  dioxid,  carbon  monoxid 
Chromium  compounds,  anilin 
Anthrax,    arsenic,    sulphur    dioxid    (see 

also  Tanning) 
Mercury 
Nitrous  gases 
Arseniuretted  hydrogen 
Arsenic,     benzin,    lead,    chrome    colors, 

methyl  alcohol,  turpentine 
Ammonia,  sulphur  dioxid 
Phosphorus 

Ammonia,  benzol,  carbon  monoxid,  car- 
bon disulphid,  sulphuretted  hydrogen, 
tar 
Nitrobenzol 
Carbon    disulphid,    ammonium    sulphid, 

nitrous  fumes 
Anilin  dyestuffs 
Phenol,  tar 
Amyl  acetate,  carbon  monoxid,  mercury, 

methyl  alcohol 
Anilin    oil,    antimony,    benzin,    benzol, 
carbon  disulphid,  cinnabar  (mercury), 
hydrochloric  acid,  lead,  sulphur  dioxid 
and  chlorid,  tar,  wood,  alcohol. 
Arsenic 

Anilin  dyestuffs 
Oxalic  acid 

Arsenic,  carbon  disulphid,  cyanogen  and 
mercury    compounds,    sulphur    dioxid 
Carbon  disulphid,  lead 
Benzol 
Nitrous  gases 
Nitrous  gases 
Ammonia,  arseniuretted  hydrogen,  acid 

fumes  and  zinc 
Arseniuretted    and    phosphuretted 

hydrogen 
Arseniuretted  hydrogen 
Carbon  monoxid,  chlorin,  arsenic 
Carbon  monoxid,  lead,  acid  fumes 
Carbon    monoxid,    other    furnace  gases 

(see  also  Cutlery  Industry) 
Ammionia,  amjd  acetate,  cyanogen  com- 
pounds, lead  solder,  hydrochloric,  nitric 
and  sulphuric  acids,  mercury,  carbon 
monoxid  (see  also  Brass) 
Arsenic 


302 


INDUSTRIAL   MEDICINE    AND    SURGERY 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR  (Continued) 


Branches  of  industry  in  which  poisoning 
may  occur 

Krems  white 
Lace  workers 
Lacquer  manufacture 

Lampblack,  manufacture 

Lamp  shades,  coloring  purposes 

Lanolin,  extraction  of 

Lard  making 

Latrines 

Laundries 


Lead  alloys 

Lead  colors 

Lead,  deoxidation  of 

Lead  metal 

Lead  smelting 

Lead  plating 

Leaf  metal  workers 

Leather  industry 

Leather  sole  stitching 

Leather  patent 

Leblanc  soda,  manufacture 

Ligroin 

Lime  chlorid,  manufacture  of 

Lime  kilns 

Linoleum,  manufacture  of 


Linotyping 

Litharge 

Lithographing 

Litho-transfer  work 

Lyddite,  manufacture  of 

Lysol 

Manchester  yellow,  manufacture  of 

Manganese  mills 

Manumeters,  manufacture  of 

Marble  polishers 

Masonic  white  leather  aprons 

Mattress,  manufacture  of 

Matches,  manufacture  of 

Meldola  dyes 

Melinite,  manufacture  of 

Mercury  compounds,  manufacture  of 

Mercury  mining 


Designation  of  industrial  poison 

Lead 

Carbon  monoxid 

Ammonia,  amyl  acetate,  benzin,  benzol, 
methyl  alcohol,  turpentine 

Phenol 

Arsenic 

Carbon  disulphid 

Acrolein,  ammonium  sulphid,  acid  fumes 

Ammonia,  sulphuretted  hydrogen 

Benzin,  benzol,  chlorin,  anilin  colors  for 
marking  ink,  carbon  monoxid,  arsenic 
from  coke  burning  ironing  stoves 

Antimony,  copper,  tin,  etc. 

Lead 

Nitrous  gases 

Arsenic 

Antimony,  arsenic,  lead,  sulphur  dioxid 

Arseniuretted  hydrogen 

Ammonia,  amyl  acetate,  acetone,  benzin, 
benzol,  methyl  alcohol,  turpentine 

Arsenic,  chromium  compounds,  lead, 
mineral  acids 

Mercury 

Amyl  acetate,  benzin,  methyl  alcohol 

Sulphuretted  hydrogen 

Benzin 

Chlorin,  arseniuretted  hydrogen 

Carbon  dioxid,  carbon  monoxid,  sulphur 
dioxid 

Acrolein,  amyl  acetate,  arsenical,  mercu- 
rial and  lead  pigments,  benzin  and 
turpentine,  manganese,  zinc  oxid 

Antimony,  arsenic,  lead,  organic  vapors 

Lead 

Arsenic,  acid  fumes,  bronze  powder, 
anilin,  benzin,  turpentine 

Lead 

Picric  acid 

Phenol 

Anilin  dyestuffs 

Manganese 

Mercury 

Lead 

Lead 

Anthrax,  infectious  diseases 

Chromium  compounds,  phosphorus 

Anilin  dyestuffs 

Picric  acid 
Mercury 

Mercury 


HEALTH    HAZARDS    IN    OCCUPATIONS 


303 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR  {Continued) 


Branches  of  industry  in  which  poisoning 
may  occur 

Mercury  smelting 
Mercury  vapor  lamps 
Metal  dipping 
Metal  burnishing 
Metal  etching 

Metal  lacquer 

Metal  pohshing 

Metal  refining 

Meters,  electric,  manufacture  of 

Methyl  amines 

Methyl  esters 

Methyl  ether 

Methyl  violet 

Methylizing  of  every  kind 

Mining 


Mineral  water,  carbonated 

Mints 

Mirbane  oil 

Mirror  plating 

Mirror  silvering 

Moulds,  drying 

Monotyping 

Moulding,  picture  frame  manufacture 

Mordant  in  dyeing 

Mosaic  works 

Muriatic  acid 

Muslin  green,  color 

Naphtha,  naphthol  nitrates 

Naphthalein 

Navy 

Nickel  buffers  and  polishers 

Nickel  platers 

Neuwied  green 

Nitric  acid  manufacture,  salts  and 

storage 
Nitrite  of  amyl 

Nitrificating  in  chemical  works 
Nitrobenzol 
Nitrocellulose 
Nitroglycerin 
Nitrojute 
Nitromannite 


Designation  of  industrial  poison 

Mercury 

Mercury 

Acid  fumes 

Antimony,  acid  fumes 

Arseniuretted  hydrogen,  nitrous  fumes, 
mercury 

Amyl  acetate 

Oxalic  acid 

Nitrous  gases 

Mercury,  lead  (see  also  Brass  Industry) 

Dimethyl  sulphate 

Dimethyl  sulphate 

Dimethyl  sulphate 

Anilin  dyestuffs 

Diazomethane 

Arsenic,  carbon  dioxid,  carbon  monoxid, 
lead,  mercury,  nitroglycerin,  nitrous 
fumes,  sulphuretted  hydrogen,  and  other 
gaseous  products  of  combustion  of  ex- 
plosive compounds 

Carbon  dioxid 

Nitrous  gases 

Nitrobenzol 

Mercury 

Acetaldehyd,  ammonia;  lead,  if  backed 
with  red  lead 

Carbon  monoxid 

Antimony,  arsenic,  acrolein,  lead 

Amyl  acetate,  bronze,  methyl  alcohol 
(see  also  Leaf  Metal  Workers) 

Antimony,  chromium  compounds,  etc. 

Manganese 

Hydrochloric  acid 

Arsenic 

Benzin,  benzol,  nitrous  gases 

Anilin,  anilin  dyestuffs 

Carbon  monoxid,  gun  firing,  and  furnace 
rooms 

Lead,  nickel-carbonyl 

Benzene,  lime,  nickel  salts,  petroleum 

Arsenic 

Nitrous  gases 

Amyl  alcohol 

Nitrous  gases 

Anilin,  nitrous  gases 

Nitroglycerin,  nitrous  gases    ■ 

Nitrous  gases 

Nitrous  gases 

Nitrous  gases 


304 


INDUSTEIAL    MEDICINE    AND    SURGERY 


LIST  OF   INDUSTRIES 


Branches  of  industry  in  which  poisoning 
may  occur 

Nitronaphthalene 

Nitrophenol 

Nitrosaccharose     , 

Nitroso  dyes 

Nitrotuluol 

Oil,  bleaching  of 

Oil,  solvent 

Oilcloth,  manufacture  of 

Oil,  vitreol 
Open  fire  heating 
Organ  builders 
Organic  dyes,  manufacture 
Organic  preparations,  manufacture 
Oxalic  acid,  manufacture  of 
Oxygen,  manufacture  of 
Painters  and  commercial  artists 


Paper  deoxidation 
Paperhangers 
Paper  mills 

Paraffin  refining 
Paris  green 
Parrot  green 
Paving  material 
Pencils,  colored 
Percussion  caps 
Perfumes,  manufacture  of 

Petroleum  industry,  distillation  and 
refining 

Pharmaceutical  preparations 

Phenol  nitrates,  manufacture  of 
Phenylhydrazin,  manufacture  of  and 
its   use    for   production   of   organic 
compounds 
Phosgene,  manufacture    of     and     its 
use  for  production  of  organic  com- 
pounds 
Phosphor  bronze 

Phosphorus     extraction     from     phos- 
phorites and  coprolites 
Phosphorus,  manufacture  of 
Phosphorus,  red,  manufacture  of 
Phosphorus,       sesquisulphid,       manu- 
facture of 


IN  WHICH  POISONING  MAY  OCCUR 

{Continued) 

Designation  of  industrial  poison 


Nitrobenzol 

Nitrobenzol 

Nitrous  gases 

Anilin  dyestuffs 

Nitrobenzol 

Chromium  compounds,  nitrous  gases 

Benzin,  carbon  disulphid 

Acrolein,  amy  lacetate,  arsenical  and  lead 
pigments 

Sulphuric  acid 

Carbon  monoxid 

Lead,  bronze,  methyl  alcohol 

Acrid  in,  arsenic 

Formaldehyd,  phenylhydrazin,  phosgene 

Oxalic  acid 

Chlorid  of  lime 

Arsenic,  benzin,  benzol,  lead,  mercury, 
methyl,  alcohol,  tar,  turpentine,  phenol, 
amyl  acetate,  carbon  disulphid 

Nitrous  gases 

Arsenic,  lead 

Chlorin,  lead,  sulphur  dioxid,  toxic  color 
pigments 

Carbon  disulphid 

Arsenic 

Arsenic 

Asphalt,  tar 

Anilin  dyestuffs 

Mercury  fulminate 

Dimethyl  sulphate,  methyl  alcohol,  nitro- 
benzol 

Petroleum,  sulphuric  acid,  hydrochloric 
acid,  chlorid  of  lime,  sulphur  dioxid, 
lead,  tar 

Mercury,  methyl  alcohol,  nitrobenzol, 
etc. 

Anilin  dyestuffs,  nitrous  gases,  phenol 

Phenylhydrazin 


Phosgene 


Phosphorus 

Phosphorus  and  hydrofluoric  acid 


Benzol,  phosphorus 
Phosphureted  hydrogen 
Phosphureted  hydrogen 


HEALTH  HAZARDS  IN  OCCUPATIONS 


305 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR 

{Continued) 


Branches  of  industry  in  which  poisoning 
may  occur 

Phosphorus  and  sulphur  compounds 

Photoengravers 

Photogen  factories 

Photographing      establishments, 

material 


Physical  apparatus,  manufacture  of 
Pianos,  manufacture  of 
Picric  acid  manufacture 

Picture  frames,  manufacture  of 

Plumbers 

Polish  for  furniture 
Polish  for  metals 
Porcelain  enamelled  ware 
Potteries 


Printing  establishments 


Preservative  fluid  for  animal  tissues 

Preservative  for  wood 

Projectiles,     manufacture     of,     filling 

shops 
Putty  making 
Putrefaction  processes,  gases  of 

Pyridin,  manufacture  of 

Pyrites 

Pyrotechniques 

Quicksilver 

Rabbit  fur  for  felt  hats 

Rag  and  shoddy  industry 

Rattan  industry 


Red  lead 

Refrigeration  plants 

Rendering  plants 

Resin,  distillation  of 

Resin,  solvent  for 

Rifle  barrel,  burnishing 

Rontgen  tuber,  manufacture  of 

Roofers 

Roofing  paper,  manufacture  of 

20 


Designation  of  industrial  poison 

Sulphureted  hydrogen 

Ammonium  dichromate,  nitrous  fumes 

Phenol 

Anilin  colors,  bromin  compounds, 
cyanogen  c,ompounds,  mercury,  metol, 
chromium  compounds,  lead  in  re- 
touching high  lights. 

Mercury,  arseniureted  hydrogen 

Bronze,  lead,  methyl  alcohol 

Anilin  dyestuffs,  nitrous  gases,  picric 
acid,  phenol 

Bronze,  amyl  acetate,  methyl  alcohol 
(see  Leaf-metal  Workers) 

Arseniureted  hydrogen,  lead,  carbon 
monoxid 

Petroleum,  methyl  alcohol 

Oxalic  acid 

Lead 

Hydrofluoric  acid,  hydrochloric  acid, 
lead,  manganese,  arsenic,  chrome, 
carbon    monoxid     (see    also  Painters) 

Acrolein,  antimony,  benzin,  lead, 
carbon  monoxid,  arsenic,  methyl 
alcohol 

Formaldehyd,  methyl  alcohol 

Arsenical  color  pigments,  phenol,  tar 

Picric  acid  (see  also  Explosives) 

Lead 

Ammonia,    carbon    dioxid,   sulphureted 

hydrogen 
Pyridin 

Arsenic,  nitrous  gases 
Antimony,  arsenic,  phosphorus 
Mercury 

Mercury,  nitrous  gases 
Acid  fumes,  infectious  diseases 
Anilin       stains,       chlorin,       chromium, 

hydrofluoric     acid,     methyl     alcohol, 

sulphur  dioxid 
Lead 
Ammonia 

Acrolein,  benzin,  carbon,  disulphid 
Carbon  monoxid 
Benzin 
Antimony 
Mercury 
Lead,  solder,  tar 
Tar 


306 


INDUSTRIAL   MEDICINE    AND    SURGERY 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR 

{Continued) 

Designation  of  industrial  poison 


Branches  of  industry  in  which 
poisoning  may  occur 

Roof  tiling  manufacture 


Rubber 
toys 


industry,'    including    rubber 


Rubber  tires,  assembling  of 

Rugs,  manufacture,  dyeing 

Rust  stains,  removal  of 

Saffron  yellow  dye 

Salamanders,      drying      houses      and 

plaster 
Sal  ammoniac 
Salts  of  mercury 
Sanitary  ware  factories 
Schweinfurth  green 
Sealing  wax,  manufacture  of 
Sewer  cleaning 

Sedimentation  tanks 

Sewing  machine  manufacture 

Sheep  dip  manufacture 

Sheele's  green 

Shellac,  solvent  for 

Shoddy  manufacture 

Shot  manufacture 

Shoe  manufacture 

Silk  bleaching 

Silk  imitation  factories 

Silk  weighting 
Silver  extraction 
Silver  metal 
Silver  plating 
Smelting  furnaces 

Smelting  lead 
Smelting  mercury 
Smelting-sulphur  bearing  ores 
Soap  factories 


Soda  carbonate,  manufacture  of 
Soda  chlorid,  manufacture  of 
Soda  sediment,  manufacture  of 
Soda  sulphate,  manufacture  of 
Soda  sulphid,  manufacture  of 
Soda  works 


Lead,  carbon  monoxid  and  other 
furnace  gases 

AniUn,  antimony,  arsenic,  benzin, 
benzol,  carbon  disulphid,  and  tetra- 
chlorid,  lead,  phenol,  sulphur  dioxid, 
and  chlorid,  tar,  mercuric  sulphid, 
methyl  alcohol,  turpentine 

Carbon  disulphid 

Arsenic  and  other  toxic  dyestuffs 

Oxalic  acid 

Anilin  dyestuffs 

Carbon  monoxid 

Ammonia 

Mercury 

Lead 

Arsenic 

Turpentine 

Ammonia,    carbon    dioxid,    sulphureted 

hydrogen 
Carbon  dioxid,  sulphureted  hydrogen 
Amyl  acetate 
Arsenic 
Arsenic 

Methyl  alcohol 

Hydrochloric  acid,  sulphuric  acid 
Antimony,  arsenic,  lead 
Benzin,  methyl  alcohol 
Sulphur  dioxid 
Carbon    disulphid,    ammonium    sulphid, 

nitrous  fumes 
Lead 

Mercury,  cyanogen  compounds 
Arsenic,  lead,  antimony 
Cyanogen  compounds,  mercury 
Carbon    monoxide    and    other    furnace 

gases 
Lead 
Mercury 
Sulphur  dioxid 
Acrolein,     nitrobenzol,     sulphuric     acid, 

pyridin,     ammonia     cyanid,     sulphur, 

tar 
Ammonia 

Hydrochloric  acid,  chlorin 
Nitrous  gases 

Arseniureted  hydrogen,  hydrochloric  acid 
Sulphureted  hydrogen 
Sulphureted  hydrogen,  hydrochloric  and 

sulphuric  acids 


HEALTH  HAZARDS  IN  OCCUPATIONS 


307 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR 

( Continued) 


Branches  of  industry  in  which 
poisoning  may  occur 


Soldering 


Staining  wood 

Stannic  acetate 

Starch,  manufacture  of 

Stamping  designs  on  embroidery 

Stamping  mills 

Stearic  acid  factories 

Stearin  refining 

Steel  engraving 

Steel  burnishing 

Stereotyping 

Storage  batteries 

Stone  and  marble  polishers 

Straw  hats,  bleaching 

Straw  de  oxidation 

Sugar,  beet  sugar 

Sugar  plants,  saturation  vessels 

Sugar  refineries 

Sulphur,  refining  of 

Sulphur  metals,  manufacture  and 
use  of 

Sulphur  extraction  in  gas  purification 

Sulphur  solvent  for 

Sulphur,  water  distillation  of 

Sulphur  and  phosphorus  compounds, 
manufacture  of 

Sulphid  colors,  manufacture  and  use 
of 

Sulphuric  acid,  manufacture  of 

Sulphurous  acid  and  salts,  manu- 
facture of 

Surgical  dressings 

Swiss  green 

Tailors 

Tallow  rendering  plants 

Tallow  refining 

Tanneries,  tanning  and  leather 
dressing 


Tapestry  printing 
Tar  color  industry 

Tar  works 
Taxidermy 
Telephone  wire,  manufacture  of 


Designation  of  industrial  poison 

Arseniureted  hydrogen,  carbon  mon- 
oxid,  hydrochloric  acid,  lead,  nitrous 
fumes 

Anilin,  chromium,  methyl  alcohol, 
phenol 

Hydrochloric  acid 

See  Putrefaction  Gases 

Lead  and  rosin 

Mercury,  nitrous  gases 

Acrolein 

Carbon  disulphid 

Mercury 

Antimony,  sulphuric  acid 

Antimony,  lead,  carbon  monoxid 

See  batteries 

Lead 

Sulphur  dioxid 

Nitrous  gases 

Ammonia 

Carbon  dioxid 

Phosphorus,  sulphureted  hydrogen 

Benzol 

Sulphureted  hydrogen 

Carbon  disulphid 
Carbon  disulphid,  sulphur  chlorid 
Sulphureted  hydrogen 
Sulphureted  hydrogen 

Sulphureted  hydrogen 

Nitrous  gases,  sulphur  dioxid 
Nitrous  gases,  sulphur  dioxid 

Mercury,  phenol 

Arsenic 

See  Garment  Workers 

Acrolein,  sulphuric  acid 

Carbon    disulphid,    chlorin,    acid    fumes 

Ammonia,  anthrax,  arsenic,  carbon 
dioxid  (in  tan  pits),  chromium  com- 
pounds, lead  (white  leather),  sulphur 
dioxid,  sulphureted  hydrogen,  acids, 
benzin,  amyl  acetate 

Turpentine,  toxic  color  pigments 

Anilin,  chromium  compounds,  phos- 
phorus, etc. 

Tar 

Arsenic,  carbon  disulphid 

Lead 


308 


INDUSTRIAL   MEDICINE    AND    SURGERY 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR 

(Continued) 


Branches  of  industry  in  which 
poisoning  may  occur 

Tempering  and  hardening,  steel 
magnets,  ,  piano  wire,  springs,  files, 
etc. 

Textile  fabrics,  deoxidation  of 

Textile  industry 

Textile  printing 

Thermometers 

Thorium,  preparation  of 

Tin  foil 

Tin  ware  and  tin  shops  and  tinning 


Tissue  hardening  and  preserving 

Toluol,  manufacture  of 

Toys,  coloring  of 

Toy  balloons,  filling 

Transfer  chromos 

Turkey  red,  mordant  for 

Typefounders 

Typesetters 

Ultramarine  works 

Upholstery 

Valeric  acid,  manufacture  of 

Varnish,  manufacture  and  use  of 

Vinegar,  manufacture  of 
Vienna  green  and  red 
Viscosin,  manufacture  of 
Vulcanizing  and  red  dyeing  of  rubber 

Wall-paper,  manufacture  of 
Wall-paper,  hangers  and  scrapers 
Waste    waters    of    industrial    plants 

making  use  of  organic  matter 
Watch  factories 


Water  gas,  carburizing 
Water  gilding 
Waterproof  material 
Wax  bleaching 
Wax  refining 
Weather  vane  gilding 
Well  gas 
Whip,  factories 
White  lead 
White  metal 
Window  shades,  green 
Wine  cellars 


Designation  of  industrial  poison 


Acrolein,  cyanogen  compounds,  lead 


Nitrous  gases 

Arsenical  colors,  lead,  sulphur'ic  acid 

Antimony,      arsenic,      chromium,      lead 

compounds 
Mercury 
Nitrous  gases 
Lead 
Ammonia,         arseniureted        hydrogen, 

chlorin,  carbon  monoxid,  hydrochloric 

acid,  lead  sulphuric  acid 
Formaldehyd 
Benzol 
Arsenic 

Arseniureted  hydrogen 
Lead 

Chromium  compounds 
Acrolein,  antimony,  arsenic,  lead 
Benzin,  lead 

Sulphur  dioxid,  sulphureted  hydrogen 
Anthrax  and  infectious  diseases 
Amyl  alcohol 
Acrolein,        ammonia,        benzin,      lead, 

methyl  alcohol,  turpentine 
Acetaldehyd 
Arsenic 
Nitrous  gases 
Antimony,      arsenic,      carbon  disulphid 

(see  also  Rubber) 
Arsenic,  lead  (see  also  Paper  Mills) 
Arseniureted  hydrogen 
Sulphureted  hydrogen 

Benzin,  cyanogen,  compounds,  lead  for 
dials,  nitrous  gases  (see  also  Brass  and 
Tempering) 

Benzol 

Mercury 

See  Rubber 

Chromium  compounds,  sulphur  dioxid 

Carbon  disulphid 

Mercury 

Carbon  dioxid 

See  Rattan  Industry- 
Lead 

Antimony 

Arsenic 

Carbon  dioxid 


HEALTH  HAZARDS  IN  OCCUPATIONS 


309 


LIST  OF  INDUSTRIES  IN  WHICH  POISONING  MAY  OCCUR 

{Continued) 

Designation  of  industrial  -poison 


Branches  of  industry  in  which 
poisoning  may  occur 

Wine  preserving 

Wire  galvanizing    with    zinc 

Wire  tempering 

Wool  bleaching 

Woolen  refuse,  deoxidation  of 

Wood  alcohol 

Wood  deoxidation  of 

Wood  impregnating  and  preserving 

Wood  staining  and  polishing 


Workrooms,  crowded 

Yeast,  compressed,  factories 

Zyloidin,  manufacture  of 

Zylol 

Zap one  lacquer 

Zinc  chlorid,  manufacture  of 

Zinc  deoxidation  of 

Zinc  ore  smelting 

Zinc  plating 

Zinc  sulphate,  manufacture  of 
Zoological  preparations 


Sulphur  dioxid 

Ammonia  arseniureted  hydrogen,  hydro- 
chloric acid,  sulphuric  acid,  zinc 

Lead,  acrolein,  cyanogen  compounds 

Sulphur  dioxid 

Nitrous  gases 

Methyl  alcohol 

Nitrous  gases 

Arsenical  paints,  phenol,  tar 

Anilin  colors,  chromium  compounds, 
lead,  arsenic  colors,  methyl  alcohol, 
alcohol  denatured  with  pyridin, 
phenol,  petroleum 

Carbon  dioxid 

Carbon  dioxid 

Nitrous  gases 

Benzol 

Amyl  acetate 

Arseniureted  hydrogen 

Nitrous  gases 

Antimony,     arsenic,     carbon     monoxid, 
lead,  manganese,  sulphur  dioxid 

Ammonia,  arseniureted  hydrogen,  hydro- 
chloric, sulphuric  acids  and  zinc 
Arseniureted  hydrogen 
Formaldehyd 


CHAPTER  XX 
\  THE  NATIONAL  SAFETY  COUNCIL 

"Safety  First"  is  the  slogan  adopted  and  made  famous  by  a 
group  of  laymen  who  in  1912  met  and  formed  the  great  National 
Safety  Council,  The  work  of  this  association  has  done  more  toward 
preventing  accidents  among  industrial  workers  than  any  other  single 
organization. 

In  1914  a  Health  Section  composed  largely  of  industrial  surgeons 
was  incorporated  as  a  part  of  this  association.  It  was  recognized 
that  Industrial  medicine  and  surgery  must  be  a  definite  part  of  any 
successful  scheme  of  accident  prevention.  The  Safety  engineer  was 
responsible  for  the  mechanical  appliances  attached  to  machines  to 
protect  the  operator  and  for  other  physical  conditions  in  the  plant 
improving  safety  methods.  The  Safety  Committee  could  spread  the 
gospel  of ''  Safety  First "  throughout  the  working  force.  But  the  doctor 
was  the  only  one  who  could  inspect  the  human  machine  and  pick  out 
defects  in  it  which  made  accidents  to  the  man  or  to  his  fellow  men 
more  liable  to  occur. 

Therefore,  with  the  induction  of  the  industrial  surgeon  into  the 
ranks  of  the  National  Safety  Council  a  complete  machine  was  formed 
for  the  prevention  of  accidents  among  industrial  employees — the 
Safety  Engineer  for  the  correction  of  physical  conditions  in  the  plant, 
the  Safety  Committees  to  spread  the  educational  propaganda  among  the 
workers,  and  the  Industrial  Surgeon,  the  Human  Engineer,  to  correct 
the  physical  conditions  in  the  employees. 

Every  industrial  surgeon  should  be  familiar  with  the  founding  and 
history  of  this  National  Safety  Council.  It  has  been  the  means  of 
conserving  thousands  upon  thousands  of  lives.  It  has  stimulated  the 
medical  profession  to  greater  efforts  in  prevention.  "Safety  First" 
is  a  twin  brother  of  Preventive  Surgery. 

Mr.  William  H.  Cameron,  the  Executive  Secretary  of  the  National 
Safety  Council,  a  man  who  has  devoted  his  life  to  this  great  humani- 
tarian movement,  has  written  the  following  history  of  this  organiza- 
tion for  the  author  to  publish  here. 

"And  the  end  is  that  the  workman  shall 
live  to  enjoy  the  fruits  of  his  labor; 
that  his  mother  shall  have  the  comfort 
of  his  arm  in  her  age;  that  his  wife 
310 


THE    NATIONAL   SAFETY   COUNCIL  311 

shall  not  be  untimely  a  widow;  that  his 
children  shall  have  a  father;  and  that 
cripples  and  helpless  wrecks  who  were 
once  strong  men,  shall  no  longer  be  a 
by-product  of  industry." 

JUHNKE. 

'"Accident  prevention  and  health  conservation  are  now  firmly 
established  among  the  institutions  of  free  America.  For  a  score 
of  years  individual  efforts  were  made  by  progressive  employers  to 
meet  the  demands  both  of  production  and  human  conservation. 
Sporadic  efforts  sought  to  gather  together  the  loose  ends  of  the  new 
industrialism,  and  to  fashion  an  organization  which  would  fit  the  needs 
of  the  twentieth  century,  but  for  lack  of  concentration  and  co-opera- 
tion   these    efforts    failed    of    lasting    accomplishment. 

"With  the  birth  of  the  American  factory  system  about  the  time  of 
the  civil  war,  came  the  doctrine  of  utility,  and,  for  a  time,  grace  and 
symmetry  in  product  were  sacrificed  to  unadorned  simplicity.  The 
cry  was  for  speed,  for  production,  for  machine  accomplishment  and  for 
'tonnage,'    and    constantly   increasing    'tonnage.' 

''The  old  tradition  of  craftsmanship  was  swept  aside  and  the  work- 
man became  a  mere  part  of  the  shop  equipment.  Short  cuts  to  produc- 
tion were  the  order  of  the  day  and  the  so-called  inherent  'risks  of  the 
trade'  became  the  doctrine  not  only  of  the  factory  but  of  the  legislative 
and  judicial  systems. 

"But  industry,  never  satisfied  with  established  order,  and  seeking 
newer  fields,  turned  from  monotonous  simplicity  and  taught  the 
public  a  new  lesson — comfort  in  living.  Following  closely  in  this 
development  came  lavishness  and  magnificence. 

''Competition  reached  a  keenness  hitherto  unknown.  Vast  capital 
was  required  and  business  management  was  alert  to  take  advantage  of 
the  growing  market.  The  world  was  scoured  for  raw  materials  for 
our  workshops,  with  the  brain  centered  on  production,  the  drafting 
rooms  became  the  lungs  of  industry,  the  sales  force  the  nerves,  the 
workshops  the  muscles  and  tendons.  Every  member  of  the  industrial 
body  except  the  heart  was  working  at  high  tension. 

"As  was  to  be  expected  reaction  set  in.  Progressive  and  thoughtful 
men  began  to  weigh  carefully  the  costs  of  operation  and  maintenance, 
and  the  utilization  of  by-products  laid  the  foundations  of  fortunes  that 
were  not  dreamed  of  under  the  law  of  'tonnage'  alone.  Economics 
and  efficiencies  in  operation,  studies  of  costs  and  closer  co-operation  in 
manufacture  logically  followed. 

"The  Safety  idea  was  born  during  the  period  of  reconstruction  of 
industry.     It   is   a   significant   fact   that   the   greatest   of    American 


312  INDUSTRIAL   MEDICINE    AND    SURGERY 

industries  was  the  first  to  amalgamate  all  the  forces  of  production  and 
utility  and  business  experience;  was  the  first,  as  an  organization,  to 
publicly  announce  a  crusade  against  industrial  accidents  and  occupa- 
tional disease.  The  Safety  movement  owes  more  to  the  United  States 
Steel  Corporation  than  to  any  other  single  business  organization. 

"The  Association  of  Iron  and  Steel  Electrical  Engineers  met  in 
Milwaukee,  Wisconsin,  the  week  of  September  30,  1912,  and  under  the 
direction  and  enthusiasm  of  Mr.  Lew  R.  Palmer,  as  Chairman  of  the 
Accident  Prevention  Committee  of  this  Association,  was  launched  the 
first  National  Safety  Congress  ever  held  in  the  United  States.  The 
resolutions  announcing  the  birth  of  the  new  order  of  industrial  justice 
are  significant: 

''  'Whereas,  The  Association  of  Iron  and  Steel  Electrical  Engineers, 
regarding  as  worthy  of  particular  attention  the  hazards  to  life  in- 
volved in  electrical  operations  in  steel  mills,  and  appreciating  the 
importance  of  the  general  Safety  movement,  not  only  in  electrical 
engineering,  but  also  in  the  steel  industry  as  a  whole,  and  in  all  the 
other  varied  and  important  industries  of  our  country,  and  having  met 
with  such  prompt  co-operation  in  their  proposals  to  establish  a  national 
organization  devoted  to  securing  increased  Safety  to  human  life, 
has  reached  the  conclusion  that  such  an  organization  can  best 
be  brought  about  by  action  at  this  joint  meeting  of  the  Association 
of  Iron  and  Steel  Electrical  Engineers  and  the  Co-operative  Safety 
Congress;  and  it  is,  therefore,  hereby 

"  'Resolved,  That  the  President  of  the  Association  of  Iron  and 
Steel  Electrical  Engineers  be  requested  to  take  the  first  steps  toward  the 
formation  of  a  national  organization  for  the  promotion  of  Safety  to 
human  life  by  appointing  a  Committee  on  Permanent  Organization, 
which  shall  contain  representatives  of  the  Federal  and  State  agencies 
already  established  to  supervise  conditions  of  Safety  in  our  industries, 
and  shall  also  contain  representatives  from  the  mining,  transportation 
and  manufacturing  industries  of  the  United  States;  and  be  it  further 

"  'Resolved,  That  the  committee  so  appointed  shall  be  and  hereby 
is  authorized  by  this  Congress  to  organize  and  to  create  a  permanent 
body  devoted  to  the  promotion  of  Safety  to  human  life  in  the  industries 
of  the  United  States;  this  Committee  to  have  authority  to  call  future 
Congresses  of  Safety,  increase  its  membership,  if  it  so  desires,  and  to 
do  such  other  acts  as  will  promote  the  object  for  which  it  is 
established.' 

"The  Congress  met  at  the  Hotel  Pfister  and  among  the  delegates 
we  find  the  following: 

Dr.  L.  W.  Chaney,  Department  of  Commerce  and  labor. 
Mr.  C.  L.  Close,  U.  S.  Steel  Corporation. 


THE  NATIONAL  SAFETY  COUNCIL  313 

Dr.  Joseph  A.  Holmes,  Director  Bureau  of  Mines. 

Mr.  F.  W.  Houk,  Commissioner  of  Labor,  Minnesota. 

Mr.  John  Kirby,  Jr.,  National  Association  of  Manufacturers. 

Mr.  James  T.  McCleary,  Iron  and  Steel  Institute. 

Mr.  Chas.  C.  McChord,  Interstate  Commerce  Commission. 

Dr.  Chas.  P.  Neill,  U.  S.  Commissioner  of  Labor. 

Mr.  L.  R.  Palmer,  Association  of  Iron  and  Steel  Electric  Engrs. 

Mr.  C.  W.  Price,  Wisconsin  Industrial  Commission. 

Mr.  R.  C.  Richards,  Chicago  and  Northwestern  Railway. 

Dr.  M.  J.  Shields,  National  Red  Cross. 

Mr.  F.  C.  Schwedtman,  National  Association  of  Manufacturers. 

Mr.  David  Van  Schaack,  Aetna  Life  Insurance  Company. 

Mr.  H.  M.  Wilson,  Bureau  of  Mines. 

Mr.  H.  J.  Young,  Illinois  Steel  Company. 

"Chairman  Dr.  Lucian  W.  Chaney,  representing  the  United  States 
Department  of  Commerce  and  Labor,  opened  the  meeting  as  follows: 

"  'I  wish  to  impress  upon  those  present  that  the  effort  in  which  we 
have  entered  in  connection  with  this  Congress  is  distinctly  a  phase  of 
applied  Christianity,  and,  therefore,  it  is  exceedingly  appropriate  that 
we  invite  Dr.  Steiner,  Professor  of  Applied  Christianity  in  Grinnel 
College,  to  offer  a  word  of  prayer  as  we  begin.' 

OPENING  PRAYER 

Dr.  Edward  A.  Steiner, 

Professor  of  Applied  Christianity,  Grinnel  College 

" '  Oh  Lord,  our  God,  who  dost  promise  to  those  who  meet  in  Thy 
name  Thine  own  presence,  we  have  come  together  not  to  consider 
our  own  weel  or  wealth;  we  have  come  here  in  Thine  own  name  to 
consider  the  well-being  of  our  fellowmen,  and  we  would  invoke 
Thy  blessing,  ask  Thee  to  meet  with  us  whom  Thou  hast  chosen  to  be 
co-workers  with  Thee.  We  pray  that  Thou  may  be  with  us  and  help 
us  not  only  to  light  the  way,  but  help  us  to  keep  the  way,  and  grant 
that  everything  that  shall  be  done  at  this  Congress  shall  work  for  the 
well-being  of  our  fellowmen,  for  the  glory  and  development  of  our  own 
country,  and  for  the  speedy  coming  of  the  kingdom  of  God.  May  our 
consideration  of  the  Safety  of  labor  and  the  toiler  be  rewarded  by  a 
higher  respect  for  humanity  as  a  whole,  a  great  regard  for  law,  a  purer 
and  deeper  and  higher  patriotism;  wilst  Thou  bless  this  city  in  which 
we  meet,  this  Commonwealth,  our  beloved  country,  the  President  of 
the  United  States,  his  Cabinet  and  all  his  officers;  this  great  country 
and  all  its  states  from  one  end  to  the  other,  and  may  it  continue  to  be 


314  INDUSTRIAL   MEDICINE    AND    SURGERY 

the  great  beacon  to  the  world,  Hghting  toward  Hberty  and  toward 
progress,  and  may  the  work  which  we  do  here  this  morning  be  a 
contribution  toward  that  end.  Bless  the  President  of  this  association, 
all  the  officers,  all  those  who  take  part,  and  may  it  be  as  solemn  as 
it  is  sacred,  and  may  it  be  as  useful  as  we  try  to  make  it  holy.  We 
ask  it  all  in  the  Master's  name,  who  gave  himself  for  the  good  of  men. 
Amen.' 

''Dr.  Chaney's  words  were  prophetic,  Dr.  Steiner's  prayer  has 
borne  fruit.  To-day  Industrial  Safety  is  firmly  established  as  a  part 
of  our  fabric  of  government.  To-day  the  gospel  of  industrial  righteous- 
ness is  preached  in  thousands  of  workshops,  and  on  the  majority  of  the 
transportation  systems. 

''  The  modest  meeting  in  1912  developed  into  the  National  Council 
for  Industrial  Safety.  Under  the  wise  leadership  of  Mr.  R.  W.  Camp- 
bell, President,  and  Mr.  William  H.  Cameron,  General  Manager, 
and  the  effective  co-operation  of  an  earnest  and  enthusiastic  staff,  the 
Safety  crusade  took  form  and  substance.  The  Second  Safety  Congress 
at  the  Hotel  McAlpin,  New  York  City,  presented  a  program  of  activi- 
ties which  commanded  the  interest  of  all  humane  employers  and 
effectively  answered  the  critics  of  the  movement.  Two  score  of  the 
biggest  and  broadest-minded  men  in  the  country  accepted  invitations 
to  address  the  Congress,  and  their  allegiance  to  the  Safety  movement 
firmly  established  the  new  crusade.  About  this  time  the  slogan 
'Safety  First'  became  popular,  welding  all  forces  of  the  newest 
gospel  into  a  concrete  and  effective  organization. 

"The  National  Council  for  Industrial  Safety  grew  and  prospered. 
The  weekly  Safety  bulletin  service  was  established  and  has  been 
continued  without  a  break  for  175  weeks,  and  has  grown  to  a  dis- 
tribution of  75,000  copies  per  week.  Statistical  researches  were  made 
and  tabulated,  and  practical  value  given  to  shop  activities  never  before 
dreamed  of.  The  innovation  of  using  available  data  in  the  simple 
and  effective  form  of  one  page  illustrated  bulletins,  rather  than  in  the 
compilation  of  massive  treatises,  proved  the  value  of  the  Council's 
services  in  teaching  the  lesson  in  readable  form  and  fresh  from  the 
press.  The  Council  doubled  its  membership  and  greatly  increased 
its  usefulness  in  this,  the  second  year,  of  its  life. 

"Then  came  the  Third  Safety  Congress,  held  at  the  Hotel  LaSalle, 
Chicago.  This  series  of  meetings  was  epoch  making,  both  in  at- 
tendance and  interest.  The  roster  of  speakers  contained  the  names 
of  Royal  Meeker,  Commissioner  of  Labor,  U.  S.  Department  of  Labor; 
John  Price  Jackson,  Commissioner  of  Labor  and  Industry,  Penn- 
sylvania; H.  M.  Wilson,  Engineer  in  Charge,  Bureau  of  Mines; 
Dean  C.  B.  Connelly,  Ida  M.  Tarbell,  Ahce  Hamilton,  Dr.  Theodore 
Sachs,  Dr.  A.  M.  Harvey,  Dr.  Geo.  W.  Price,  Martin  J.  InsuU,  William 


THE    NATIONAL    SAFETY    COUNCIL  315 

P.  Eno,  E.  A.  Halsey,  Fred  C.  Schwedtman  and  a  host  of  others, 
all  preaching  and  advocating  industrial  Safety  and  health  conservation. 

"It  was  at  this  Congress  that  the  industrial  medical  practitioner 
first  made  his  voice  heard  in  unmistakable  terms.  Plant  managers 
learned  that  the  installation  of  adequate  mechanical  safeguards  did 
not  comprise  their  only  duty.  Sanitation,  ventilation,  control  and 
eradication  of  industrial  disease,  elimination  of  communicable  in- 
fections, all  these  and  other  questions  were  placed  on  the  program 
and  given  a  thorough  discussion.  Tuberculosis,  blood  poison,  hernia, 
eye  strain,  and  excessive  fatigue  were  handled  in  a  way  to  awaken 
the  interest  and  co-operation  of  the  large  audiences. 

"A  year  of  intense  activity  followed.  With  the  broadened  scope 
of  activities  the  association  changed  its  name  to  'National  Safety 
Council.'  The  program  of  the  Third  Safety  Congress  furnished 
the  text  for  the  activities  of  the  officers  and  members  and  the  work 
was  carried  on  with  renewed  enthusiasm.  The  membership  doubled, 
and  with  every  mail  came  scores  of  experience  statements  from  plant 
officials  to  be  compiled,  digested,  and  reissued  for  the  information  of 
the  whole  membership. 

"  Mr.  Arthur  T.  Morey  honored  the  Council  by  accepting  the  office 
of  chief  executive  for  the  third  year,  Mr.  Campbell  retiring  as  Presi- 
dent at  the  end  of  the  second  year.  It  is  significant  of  the  interest 
taken  in  the  work  that  the  master  minds  of  industry  have  cheerfully 
and  unostentatiously  given  so  liberally  of  their  time  and  experience 
for  the  causes  of  safety  and  humanity. 

"The  Fourth  Safety  Congress  was  held  at  the  Belle vue-Stratford 
Hotel,  Philadelphia.  To  meet  the  demands  of  the  Congress  it  was 
necessary  to  divide  the  Council  into  sections,  each  meeting  larger 
in  attendance  and  more  ambitious  in  program  than  the  first  Congress 
at  Milwaukee,  The  Governor  of  the  Commonwealth,  the  Mayor 
of  this  City,  the  press,  and  the  public  united  in  a  grand  rally  to  further 
the  propaganda  of  the  Congress. 

"After  the  great  'round  table'  gatherings,  devoted  to  general  dis- 
cussion, ten  sectional  meetings  considered  the  particular  Safety  prob- 
lems of  their  industries.  The  Cement  Section  took  a  leading  part 
in  the  Congress,  as  did  the  Mining,  Steam  Railroad,  Laundry,  Paper 
and  Pulp  Manufacturers,  Public  Utilities,  Textile,  Industrial  Hygiene, 
Safeguarding   of    Machinery,    Foundry   and    Woodworking  Sections. 

"It  was  at  this  gathering  that  the  greatest  truth  in  the  Safety  Cru- 
sade was  forcibly  driven  home  to  the  plant  managers,  the  Safety 
Engineers,  and  the  public,  namely,  that  all  the  safeguards,  all  the  rule 
books,  all  the  discipHne,  and  all  other  efforts  must  fail  without  the 
earnest  and  willing  co-operation  of  the  workmen  themselves.  Mil- 
lions of  dollars  had  been  expended  by  the  members  of  the  National 


316  INDUSTRIAL    MEDICINE    AND    SURGERY 

Safety  Council  in  perfecting  the  mechanical  safeguards  in  their  plants; 
other  millions  went  for  sanitation,  for  ventilation,  for  preventive 
measures,  yet  the  men  vitally  affected  too  often  showed  only  a  per- 
functory interest  in  their  own  welfare. 

"A  scoTe  of  addresses  and  lectures  were  delivered  at  the  Philadel- 
phia Safety  Congress  pointing  the  way  to  success  ?n  administering 
Safety  work — ^the  way  to  the  hearts  of  the  millions  of  men  and  women 
toiling  in  the  industries.  The  visiting  nurse,  the  industrial  physi- 
cian, the  dentist,  and  the  teacher  came  forward  and  joined  the  social 
worker,  priest  and  parson  in  the  teaching  of  applied  and  practical 
Christianity.     Industrial   justice   was   heard   in   no   uncertain   terms. 

"Another  important  lesson  was  taught  out  of  the  wealth  of  digested 
experience  and  statistical  data  furnished  through  the  medium  of 
the  parent  body — the  National  Safety  Council.  Where  one  accident 
was  prevented  through  safeguarding  three  were  prevented  by  the 
exercise  of  personal  care  and  caution  by  the  workmen  themselves. 
Where  one  case  of  industrial  disease  was  prevented  in  the  shop  or 
factory,  two  were  susceptible  of  prevention  and  three  of  cure  in  the 
home  life  of  the  employees. 

'  'From  the  date  of  the  Fourth  Safety  Congress  the  importance  of 
education,  rather  than  compulsion  in  Safety  matters,  was  given  promi- 
nent place  in  the  activities  of  the  movement. 

"The  elasticity  of  the  Council  was  never  better  exemplified  than 
during  the  succeeding  year.  Employers  who  had  held  aloof,  waiting 
for  the  movement  to  prove  itself,  came  forward  in  whole-hearted 
recognition  of  the  justness  of  the  plea  for  a  larger  humanity.  From 
an  organization  struggling  to  meet  the  patent  demands  made  upon 
it  in  the  simple  necessities  of  everyday  life,  the  Council  almost  in  a 
day,  was  placed  beyond  the  need  of  financial  worries. 

"From  the  Fourth  to  the  Fifth  Safety  Congresses  the  membership 
again  doubled  in  number;  the  work  of  the  Sections  was  improved, 
an  increased  staff  at  headquarters  facilitated  the  activities  of  the 
officers,  and  the  newer  phases  of  Safety  work  were  pushed  with  un- 
relenting vigor.  The  record  of  the  Fourth  Congress  is  found  in  the 
771  pages  of  the  proceedings  of  the  gatherings — a  living  monument 
of  service  and  a  text-book  on  safety  of  incalculable  value. 

"The  Fifth  Safety  Congress  was  held  at  the  Hotel  Statler,  Detroit. 
Mr.  Lew  R.  Palmer  succeeded  Mr.  Morey  as  President,  Mr.  Morey 
continuing  (as  in  the  case  of  Former  President  Campbell)  as  a  director 
and  Executive  Committeeman  of  the  Council.  The  proceedings  of 
the  Fifth  Safety  Congress  fill  a  volume  of  1541  pages,  every  page 
a  lesson  and  an  inspiration. 

"Perhaps  the  most  important  constitution  for  the  cause  of  Safety 
by  the  National  Safety  Council,  has  been  the  organization  and  es- 


THE    NATIONAL   SAFETY    COUNCIL  317 

tablishment  of  an  Information  Bureau  and  Library  of  every  scrap 
of  printed  material  available  in  the  United  States  and  foreign  coun- 
tries, relating  to  the  work  of  the  Council.  This  Information  Bureau 
is  at  present  in  charge  of  two  trained  librarians  who  are  classifying 
and  filing  this  printed  information,  and  sending  it  to  the  hundred  of 
members  inquiring  for  data  every  month.  Every  application  for 
membership  passes  through  this  Bureau  of  Information,  and  the  im- 
portant bulletins  and  publications  of  the  Council  are  sent  to  the 
new  member  to  properly  start  him  in  his  new  activities.  For  the 
year  ending  April  1,  1917,  four  million  bulletins  were  distributed  to  jBf- 
teen  thousand  representatives  residing  in  every  State  of  the  Union, 
and  in  seven  foreign  countries. 

"At  the  present  time  the  monthly  pamphlet  called  "Safe  Practices" 
is  in  circulation,  an  encyclopedic  work  destined  to  take  its  place  in 
literature  with  the  foremost  handbooks  of  the  world.  A  modest  num- 
ber on  'Ladders'  was  followed  by  others  on  'Stairs  and  Stairways;' 
'Boiler  Rooms;'  'Crane  Construction  and  Safe  Practices;'  'Knots, 
Slings,  Bends  and  Hitches;'  'Belt  Shifters,'  etc.  In  time,  it  is  in- 
tended to  present  every  phase  of  industrial  education  and  by  rule, 
illustration  and  practice,  complete  a  digest  of  Safe  Practices  for  the 
prevention  of  accidents  in  the  industries  of  America. 

"In  attempting  a  brief  resume  of  the  work  of  the  Council  it  is  weU 
to  digress  from  its  direct  accomplishments  to  point,  if  only  momen- 
tarily, to  the  reflection  of  its  activities  on  other  forces  in  society. 
Take  from  the  shelf  of  any  Hbrary  devoted  to  law,  medicine,  pub- 
lic or  private  welfare  any  volume  published  in  the  last  four  or  five 
years  and  run  through  the  pages.  You  will  find  therein,  whether 
in  federal  enactment,  state  law,  or  city  ordinance,  chapters,  phases, 
and  texts  first  enunciated  at  the  Congresses  of  the  National  Safety 
Council. 

"In  this  way  is  the  history  of  the  movement,  and  the  mommaent 
to  its  founders  and  proponents,  best  perpetuated — in  the  lives  and 
hearts  of  Kving  men  and  women;  in  the  healthy  bodies  and  active  minds 
of  self-supporting  and  self-respecting  workers,  due,  in  many  thou- 
sands of  cases,  to  the  whole-hearted  co-operation  of  their  employers 
in  makiag  this  a  better  and  a  safer  country." 


CHAPTER  XXI 
ACCIDENT  PREVENTION  / 

Entire  volumes  have  been  written  in  recent  years  on  the  subject 
of  accident  prevention.  In  the  last  decade  few  topics  connected  with 
industry  have  received  more  attention  or  made  more  rapid  progress. 
And  yet  the  prevention  of  injuries  to  our  workmen  has  not  reached 
a  high  plane  of  efficiency,  and  in  many  concerns  it  is  still  more  or  less 
neglected. 

In  some  nations  the  conservation  of  their  people  has  caused  high 
penalties  to  be  placed  against  those  employers  who  fail  to  prevent 
injuries  from  occurring  to  their  employees.  As  a  result,  accident  pre- 
vention has  become  standardized  throughout  their  entire  industrial 
field,  resulting  in  great  saving  in  life  and  limbs.  In  the  United  States 
the  introduction  of  employees'  compensation  laws  caused  many  con- 
cerns to  adopt  some  system  of  accident  prevention.  But  thus  far 
these  laws  have  not  been  drastic  enough  to  place  a  penalty  upon  the 
concerns  failing  to  take  proper  precautions. 

In  a  few  states,  as  for  example  Ohio,  the  accident  insurance  of 
all  concerns  is  carried  by  the  state  government.  The  amount  of 
premium  paid  by  the  employer  is  raised  or  lowered  each  year  accord- 
ing to  the  number  of  compensable  injuries  which  his  employees  sus- 
tained during  the  preceding  year.  This  arrangement  gave  an  im- 
petus to  the  prevention  of  accidents  among  all  industries  in  that  state. 
While  some  concerns  will  voluntarily  institute  this  form  of  prevention, 
yet  it  will  not  become  universal  until  our  nation  makes  it  too  expen- 
sive for  any  employer  to  allow  preventable  injuries  to  occur.  It 
is  imperative  that  every  industrial  surgeon  should  drive  home  this 
truth  at  every  opportunity — Prevention  is  much  Cheaper  than  pay- 
ing Compensation. 

Many  laymen  have  entered  this  field  of  preventive  surgery.  Safety 
engineering  has  become  a  great  specialty.  Such  an  engineer  is 
very  essential  as  the  prevention  of  many  accidents  depends  upon 
building  construction,  mechanical  appliances  adapted  to  machinery, 
the  rebuilding  of  some  machines,  and  many  other  forms  of  mechanical 
work.  But  no  surgeon  should  neglect  to  familiarize  himself  with 
every  form  of  accident  prevention. 

It  is  impossible  to  cover  the  entire  scope  of  this  work  in  a  volume 
devoted  to  so  many  other  subjects  related  to  Human  Maintenance, 

318 


ACCIDENT    PREVENTION  319 

but  the  author  would  recommend  the  Transactions  of  the  National 
Safety  Council,  and  the  book,  "Accident  Prevention  and  Relief" 
by  Schwedtman  and  Emery,  pubUshed  by  the  National  Association 
of  Manufacturers,  to  every  surgeon  engaged  in  industrial  practice. 
In  this  chapter,  however,  we  will  endeavor  to  show  the  relationship 
of  the  surgeon  in  industry  to  all  accident  prevention  work,  and  point 
out  the  responsibilities  which  are  his  by  many  examples  derived  from 
actual  experience. 

Industrial  accidents  may  be  etiologically  divided  into  three  groups : 

1.  Those  due  to  the  physical  conditions  found  in  the  working 
place. 

2.  Those  due  to  certain  physical  or  mental  conditions  found  in 
the  working  force. 

3.  Those  due  to  disaster,  as  j&res,  lightning,  explosion,  cyclone, 
etc. 

The  prevention  of  accidents  must  be  done  by : 

1.  Protection  against  potential  accidents  by  safety  appliances 
placed  about  the  working  place,  or  worn  by  the  employees. 

2.  A  study  of  the  cause  of  an  accident  and  protection  against  a 
recurrence. 

3.  Supervision  of  the  physical  and  mental  condition  of  all  em- 
ployees and  correction  of  any  causes  for  accident  found  in  them;  the 
removal  of  a  susceptible  employee  to  work  where  no  hazard  exists; 
the  safeguarding  of  fellow  employees  from  accidents  liable  to  result 
from  defective  workmen. 

4.  Protection  against  disaster  as  far  as  possible  and  providing 
proper  means  of  escape  for  the  employees  in  case  of  disaster. 

To  accomplish  the  above  Accident  P*revention  there  must  be: 

1.  Constant  study  and  inspection  of  the  physical  conditions 
of  the  working  place,  by  the  safety  engineer,  the  medical  staff,  the 
management  and  the  employees,  to  discover  causes  for  the  potential 
accidents. 

2.  Careful  study  of  the  cause  of  each  accident  by  the  surgeon  and 
safety  engineer  to  ascertain  whether  mechanical  conditions  or  condi- 
tions in  the  employee,  or  both,  were  responsible  and  how  a  like  acci- 
dent can  be  prevented  in  the  future. 

3.  Educational  campaigns  on  accident  prevention  by  bulletins, 
lectures,  motion  pictures,  by  safety  committees  among  employees,  and 
by  developing  an  atmosphere  of  Prevention  throughout  the  entire 
working  force  (Fig.  39). 

Before  the  ''Safety  First"  movement  started  the  greatest  number 
of  accidents  were  due  to  the  physical  conditions  of  the  working  place. 
This  is  still  true  in  many  concerns.  But  as  protective  appliances  were 
installed,  accidents  from  these  causes  decreased,  and  conditions  found 


320 


INDUSTRIAL   MEDICINE    AND    SURGERY 


in  the  employees  themselves  became  more  evident  as  a  causative 
factor. 

The  commonest  cause  of  injury  was  found  in  minor  accidents, 
such  as  those  due  to  splinters,  pin  pricks,  nail  wounds,  scratches 
from  loose  wire,  from  tools,  contusions  as  from  hammer  blows, 
tripping  on  loose  boards,  slipping  and  falling,  etc.  Even  these  minor 
accidents  have  been  greatly  reduced.     But  the  greatest  benefits  have 


ACCIDENT  PREVENTION  POSM 


Number  1 1. 


8  Men  Killed-Each  Death  A  Preventable  Accident 

I — ^Workman  engaged  in  h»v^ing  loail  of  cut  wocxL    Load  toppled  over  on  him  and  hd 
died  of  hi*  iiyurie*. 

PILE  ALL  MATERIAL  SAFELY. 

S — Fhre  workmen  recently  killed  in  different  parti  of  State  coming  in  contact  with  live 
wires. 

PROPERLY   PROTECT  ALL  ELECTRIC  WIRES. 

DO  NOT  TOUCH  WIRES  UNLESS  YOU   KNOW  DANGEROUS 
CURRENT  IS  CUT  OFF. 


REPORT   ALL    INJURIES  AT   ONCE   AND   RECEIVE    PROPER 
MEDICAL  ATTENTION. 

1 — Crane  lifting  plank*.     One  plank  slipped  from  load  and  hit  workman  on  head, 
killing  him. 

KEEP  FROM   UNDER  SUSPENDED   LOADS. 

8  Persons  Unnecessarily  Killed. 


SORROW,  SUFFERING,  POSSIBLY  WANT-ALL  AVOIDED  BY  CAREFULNESS. 


COMMONWEALTH  OF  PENNSYLVANIA 
DEPARTMENT  OF  LABOR  AND  INDUSTRY 

JOHN  PRICE  JACKSON.  Commuiloo.r. 


Fig.  39. — Actual  facts  make  the  best  propaganda  for  prevention. 

come  from  early  treatment  of  these  conditions  thereby  preventing  any 
serious  complications  from  arising. 

The  surgeon  in  charge  of  the  "Human  Maintenance"  Department 
of  an  industry  should  be  most  keenly  alive  to  the  responsibility  of 
accident  prevention.  It  is  one  of  the  most  important  branches 
of   preventive   Surgery. 

MAJOR  ACCIDENTS 

We  will  first  take  up  the  physical  conditions  in  the  working  place, 
which  may  cause  these  accidents. 


ACCIDENT   PREVENTION  321 

Every  building  connected  with  the  plant  should  be  thoroughly 
inspected  to  see  that  potential  causes  of  accidents  do  not  exist,  or 
if  found,  that  they  are  corrected. 

The  building  should  be  strongly  constructed  so  that  it  can  stand 
the  strain  placed  upon  it.  This  is  an  engineer's  or  architect's  job, 
you  will  say.  This  is  true  but  wherever  the  least  doubt  exists  the 
industrial  surgeon  should  see  that  this  expert  advice  is  brought  in  to 
safeguard  the  employees.  Every  year  severe  injuries  and  deaths  occur 
from  the  collapse  of  some  building  or  scaffolding  used  in  connection 
with  industry.  The  surgeon  thinking  in  terms  of  prevention  should 
be  the  first  to  point  out  these  dangers.  He  should  know  at  all  times 
if  the  buildings  used  by  his  concern,  or  any  temporary  structures 
which  are  erected,  are  safe. 

Darkness  is  a  Breeder  of  Accidents. — Every  place  in  the  building 
where  employees  must  work  or  pass  through  should  be  adequately 
lighted.     This  is  particularly  true  of  all  stairways  or  gangways. 

All  platforms  or  other   elevations   should  be  protected. 

Unprotected  Elevator  Shafts  are  the  Cause  of  Frequent  Accidents. 
— Every  known  safety  device  should  be  placed  on  elevators.  Too 
-often  we  wait  until  an  elevator  accident  occurs  before  taking  proper 
precautions.  Every  gate  to  an  elevator  should  be  raised  or  lowered 
automatically  when  the  elevator  stops  or  before  it  can  start. 

Three  garages  were  recently  visited  in  a  certain  city,  in  which  the 
elevator  gates  were  not  used  at  all.  The  elevator  was  run  by  any 
customer  who  came  in  and  desired  to  go  to  the  second  or  third  floor 
for  his  car.  This  carelessness  is  bound  to  result  in  accident  sooner 
or  later. 

Laws  preventing  such  carelessness  should  be  enacted  and  strictly 
enforced.  The  prevention  surgeon  should  consider  it  his  duty  to 
report  such  conditions  to  the  proper  authorities.  In  other  words, 
the  prevention  instinct  in  each  should  react  not  only  for  the  good  of 
the  employees  under  us  but  for  the  good  of  mankind. 

Temporary  structures  such  as  scaffoldings  are  notorious  as  a  cause 
for  accident  due  to  collapse.  One  industrial  surgeon  persuaded  the 
manager  to  rule  that  no  temporary  structure  could  be  used  until  it 
had  been  thoroughly  inspected  by  the  safety  engineer  and  pronounced 
perfectly  safe  by  him. 

The  Failure  to  Keep  the  Building  in  Repair  at  All  Times  Is  Often 
Cause  for  Accidents.^ — An  employee  reported  to  the  doctor's  office,  in 
a  certain  concern,  with  all  the  flexor  tendons  of  the  wrist  severed  due 
to  striking  it  against  a  broken  window  pane.  Inquiry  revealed  the 
fact  that  this  window  pane  had  been  broken  for   over  six  months. 

In  a  busy  concern,  a  heavy  truck  broke  one  of  the  boards  in  the 
floor.     A  week  later  an  employee  tripped  on  this  broken  board  and  fell 

21 


322 


INDUSTRIAL   MEDICINE    AND    SURGERY 


striking  his  head  against  the  sharp  corner  of  a  box.  He  suffered  a 
Pott's  Fracture  and  a  skull  fracture.  The  repair  of  this  defective 
floor  would  have  prevented  both.  The  sharp  edge  of  the  box  left 
exposed  so  near  the  aisle  was  a  potential  cause  for  accident. 

Every  plant  physician  can  recall  many  preventable  cases  which  have 
resulted  from,  broken  conditions  left  unrepaired. 

Loose  Articles  Left  on  Floors  or  on  Shelves  or  Other  Elevations 
are  Dangerous. — Four  employees  were  assigned  the  job  of  moving  a 
heavy  machine.'  When  they  had  finished,  one  of  them  threw  his  crow- 
bar down  in  the  aisle.  Another  employee  passing  that  way  stumbled 
over  the  bar  and  fell  forward  into  the  pit  where  the  machine  had 
formerly  stood.     A  broken  humerus  was  the  result. 


Like  ihese  may  puncture 
your  feet.  Throw  old. 
lumber  on  scrap  pile  or 
turn,  boards  so  nails 
point  DOWNWARD 

Keep  your  shoes  in  good  con 
dition  so  thai  nails  or  slivers 
cannot  punch  through  soks 


Personal  Caution  is  the 
Greatest  Safeguard 


Fig.  40. — Placards  similar  to  this  should  be  posted  throughout  the  plant. 
{Courtesy  Conference  Board  Safety  and  Sanitation.) 


An  employee  engaged  in  opening  a  crate  left  the  loose  boards  with 
nails  in  them,  lying  on  the  floor.  A  second  employee  stepped  on  one 
of  the  nails  and  developed  a  severe  infection  which  resulted  in  three 
months'  lost  time  from  work  (Fig  40). 

After  a  building  was  completed,  a  loose  brick  was  left  on  a  cross 
beam  over  an  aisle.  One  day,  without  any  apparent  cause,  it  dropped 
just  as  the  foreman  of  that  department  was  passing.  It  gave  him 
a  very  severe  scalp  wound.  The  peculiar  coincident  about  this,  ac- 
cording to  the  foreman,  was  that  "he  had  seen  that  brick  there  every 
day  for  months. "  If  a  keen  prevention  sense  had  been  developed  in 
the  employees  of  this  concern,  no  brick  would  have  been  left  in  such 
a  dangerous  position. 


ACCIDENT   PREVENTION  323 

Protection  of  Employees  from  Falling  Material.^ — The  careless 
stacking  of  boxes,  barrels,  filled  sacks,  jEiles  of  paper,  of  lumber,  of 
pipes,  and  of  other,  material,  often  results  in  the  severest  kind  of 
accidents. 

A  new  employee  was  assigned  to  stacking  200  lb.  sacks  of  sugar 
in  a  warehouse.  He  piled  them  to  the  roof  in  a  careless  manner.  Sud- 
denly the  sacks  started  to  roll  and  an  avalanche  of  them  fell  upon  the 
employee,  breaking  his  back. 

The  foreman  was  to  blame  in  this  case  because  he  had  failed  to  give 
proper  instructions  to  his  man. 

Old  or  broken  machinery,  broken  tools,  other  appliances  in 
similar  condition  are  frequent  causes  of  accidents. 

The  explosion  of  old  boilers  became  such  a  notorious  cause  of 
accidents  that  boiler  inspection  became  a  legal  necessity. 

Broken  ladders  have  caused  many  a  broken  head  or  fractures  in 
other  bones. 

>  In  one  concern  a  cracked  emery  wheel  was  left  unrepaired  for 
several  months  as  it  was  not  used  frequently.  One  day  while  in 
operation  it  broke  into  a  thousand  pieces.  One  man  was  permanently 
blinded  and  two  others  lost  time  on  account  of  injuries. 

Thousands  of  examples  could  be  collected  of  accidents  resulting 
from  unrepaired  apparatus  used  by  employees.  Business  men  intent 
upon  the  larger  problems  connected  with  their  plants  often  neglect 
these  smaller  leaks  which  uncorrected  are  a  source  of  great  financial  loss 
to  them.  The  plant  physician  is  the  logical  person  to  point  out  these 
conditions. 

In  one  industry  hand  infections  were  very  frequent  among  the 
employees  in  the  packing  room.  These  usually  resulted  from  minor 
injuries  such  as  scratches,  nail  wounds,  splinters,  etc.  Finally  the 
surgeon  made  an  investigation  to  ascertain  the  causes  of  these 
minor  accidents.  He  found  that  nails  were  scattered  on  the  floor  and 
that  boards  with  nails  in  them  were  lying  about  ready  to  cause  naU 
wound.  Goods  were  brought  to  the  department  in  large  baskets. 
Some  of  these  baskets  were  old  and  the  cause  of  many  of  the  scratches 
and  splinters  was  discovered  in  them.  The  bins  where  the  goods 
for  packing  were  dumped  were  lined  with  tin.  In  some  of  the  bins 
this  tin  was  loose  and  furnished  a  sharp  edge  where  many  small  cuts 
could  occur.  Many  other  apparently  trivial  conditions  were  found 
as  a  cause  for  these  minor  accidents. 

In  making  this  inspection  the  men  in  the  department  were  freely 
consulted  as  to  how  these  scratches  and  splinter  wounds  were  caused, 
and  many  valuable  hints  for  correction  of  the  same  were  thus  obtained. 
The  spirit  of  prevention  was  injected  into  the  men  by  thus  seeking 
their  co-operation. 


324  INDUSTRIAL    MEDICINE    AND    SURGEIIY 

After  the  management  was  apprised  of  these  conditions,  steps 
were  taken  to  prevent  them.  Every  employee  became  a  committee 
of  one  to  keep  nails  off  the  floor  and  out  of  the  way.  A  man  was  given 
the  job  of  keeping  all  baskets  in  perfect  repair,  and  the  foreman  was 
told  to  make  a  daily  inspection  of  all  bins  and  keep  them  repaired. 

These  precautions,  combined  with  the  immediate  use  of  iodin 
when  a  minor  injury  occurred,  practically  did  away  with  serious 
infections  from  this  department. 

This  rather  detailed  report  is  given  as  one  of  the  best  examples  of 
the  work  of  the  surgeon  in  accident  prevention.  It  also  points  out  the 
importance  of  keeping  all  physical  conditions  about  the  plant  in  repair. 

Safety  appliances  on  machinery  have  been  the  means  of  reducing 
major  accidents  to  employees  to  a  very  marked  extent.  Most  con- 
cerns engaged  in  heavy  work  such  as  the  steel  mills,  electrical  industries, 
railroads,  and  hundreds  of  others  have  safety  engineers  who  devote 
their  entire  time  to  safeguarding  machinery.  The  great  number 
of  machines  that  can  be  safeguarded  and  the  variety  of  appliances 
make  it  impossible  to  go  into  detail  about  this  form  of  prevention. 
The  Safety  First  movement  has  made  it  familiar  to  all.  The  few 
illustrations  given  will  elucidate  to  every  student  of  the  subject  the 
importance  of  familiarizing  himself  with  the  specific  appliances. 

It  is  a  human  trait,  however,  to  grow  careless.  "  Familiarity  breeds 
contempt"  is  too  often  exemplified  by  the  old  workman  losing  a  limb 
on  a  dangerous  machine  with  which  he  was  so  familiar  that  he  neglected 
to  use  the  safety  appliance.  A  careful  history  of  the  accident  taken 
by  the  surgeon  will  reveal  this  neglect.  The  doctor  should  report 
this  to  the  safety  engineer  or  whoever  is  responsible  for  making  the 
men  use  the  appliances.  He  can  also  use  this  history  as  a  text  for 
a  bulletin  pointing  out  to  the  fellow  employees  how  John  Doe  lost 
his  hand  by  neglecting  to  protect  his  saw  with  the  safety  frame. 

In  other  words,  the  doctor  is  in  the  logical  position  to  prevent 
carelessness  on  the  part  of  the  men  or  on  the  part  of  the  management 
when  there  is  a  tendency  to  neglect  this  form  of  prevention. 

It  frequently  happens  that  the  safety  device  adopted  by  the  safety 
engineer  is  not  adapted  to  the  machine  and  interferes  with  output. 
In  such  a  case  the  men  will  often  deliberately  neglect  to  use  it.  Or, 
the  safety  device  itself  may  be  the  direct  cause  of  the  accident. 

As  an  example  of  this  latter  condition,  I  recall  two  serious  accidents 
which  occurred  as  the  result  of  a  safety  tread  which  was  placed  upon  a 
stairway.  It  was  a  stairway  which  led  into  a  basement  and  was  used 
chiefly  by  the  women  employees.  No  accidents  had  occurred  here 
but  the  safety  engineer  thought  he  would  anticipate  trouble  by  cover- 
ing the  steps  with  a  new  type  of  safety  tread.  Shortly  after  it  was 
installed  a  girl  caught  her  heel  upon  the  iron  tread  and  fell  down  the 


ACCIDENT    PREVENTION  325 

steps,  fracturing  her  arm.  The  fact  was  reported  to  the  safety  engineer. 
His  report,  however,  blamed  the  cause  upon  the  high  heeled  shoes 
worn  by  the  girl.  The  next  day  another  girl  fell  down  these  steps,  but 
no  serious  consequence  resulted.  A  week  later  a  third  girl  caught  her 
heel  in  the  same  way,  falling  and  injuring  her  leg. 

It  is  needless  to  say  that  this  "safety  device"  was  removed,  but 
only  because  the  doctor  followed  up  each  history  and  was  thus  able  to 
point  out  the  cause. 


Fig.  41. — Properly  guarded  grinding  wheel.      {Courtesy  General  Electric  Co.) 

The  high  heeled  shoe  worn  by  an  employee  illustrates  another  cause 
of  accidents — those  due  to  faulty  wearing  apparel.  The  shoe  with  a 
loose  sole  often  is  the  cause  of  falls.  Or  the  worn  sole  will  allow 
injuries  from  nails  or  splinters.  A  loose  sleeve  may  get  caught  in 
machinery,  pulling  the  arm  in  and  causing  a  severe  accident. 

An  employee  was  oiling  a  shaft  live  feet  above  the  floor.  He 
had  a  loose  sleeve,  and  besides  was  doing  the  work  while  the  shaft 
was  in  motion- — a  condition  that  should  never  be  tolerated.  The 
sleeve  caught  and  the  man  was  whirled  around  the  shaft  three  times 
before  the  torn  sleeve  released  him.  His  injuries  caused  fourteen 
months  lost  time  and  permanent  disability. 


326 


INDUSTRIAL    MEDICINE    AND    SURGERY 


A  safety  appliance  attached  to  the  employee  is  another  means  of 
prevention.  The  best  example  of  this  is  the  wearing  of  goggles  in 
emery  grinding  or  in  any  work  where  steel  or  other  material  may  fly 
in  the  eyes.  Here  again  the  surgeon  will  find  it  necessary  to  constantly 
watch  the  employees  to  see  that  they  observe  this  form  of  prevention. 

Dr.  Irving  Clark  of  the  Norton  Grinding  Works  has  some  wonderful 
figures  showing  the  almost  complete  eradication  of  eye  injuries  among 
their  employees  by  not  only  supplying  goggles  to  the  men  but  by, 


Fig.  42. — Incorrect  way  of  using  goggles.      {Courtesy  General  Electric  Co.) 


enforcing  their  use.  Educational  campaigns  are  the  greatest  means 
of  securing  the  co-operation  of  the  men  in  this  form  of  prevention. 
Old  emery  grinders  scorned  this  protection  at  first.  Among  these  old 
timers  were  one  or  two  men  very  adept  at  removing  emery  from  the  eye 
— "the  eye  doctors  of  the  plant."  Combined  with  the  use  of  goggles 
it  was  necessary  to  teach  the  men  to  report  at  once  to  the  doctor 
if  any  particles  flew  in  the  eye.  The  dangers  of  allowing  a  fellow 
employee  to  fool  with  the  eye  was  impressed  upon  the  men  in  a 
dozen  different  ways  until  at  last  this  rule  was  observed  by  all. 

One  day  in  a' box  factory  where  old  boards,  occasionally  with 
nails  in  them,  were  sawed  up,  an  employee  was  struck  in  the  eye  by 


ACCIDENT   PREVENTION 


327 


a  flying  nail.  His  goggles  were  around  his  neck.  He  had  neglected  to 
use  them  because  his  foreman,  an  old  timer,  didn't  insist  upon  his  men 
using  the  "fool  things."  The  loss  of  the  eye  resulted.  The  history  of 
the  case  was  posted  throughout  the  plant  by  the  surgeon  as  propaganda 
in  favor  of  goggles.  The  next  day  a  nail  again  flew  from  a  board  and 
struck  the  goggles  being  worn  by  the  employee.  The  glass  over  one 
eye  was  cracked  in  a  hundred  places  but  the  eye  was  saved.  It  was 
an    act    of    Providence    for  the  broken  goggle  was  shown  to  every 


Fig.  43. — Correct  way  of  using  goggles.      {Courtesy  General  Electric  Co.) 


employee  in  that  department  and  this,  combined  with  the  recent  case  of 
blindness,  drove  the  lesson  home.  Even  the  foreman  was  converted 
but  this  didn't  save  his  job  (Fig.  44). 

Whenever  goggles  are  used  the  glass  should  be  of  the  best  material 
— that  which  \\  ill  crack  but  will  not  fly  into  splinters.  A  number  of 
such  goggles  are  made. 

Many  other  appliances  worn  by  employees  will  prevent  accidents. 
The  study  of  each  history  of  accident  will  enable  the  surgeon  to  suggest 
many  such  means  of  prevention. 


328 


INDUSTRIAL    MEDICINE    AND    SURGERY 


We  will  next  consider  the  second  class  of  accidents:  those  due 
to  some  physical  or  mental  condition  found  in  the  employees. 

It  is  quite  obvious,  even  to  some  hardened  foremen,  that  if  a  man 
who  is  blind  in  one  eye,  or  who  has  lost  an  arm,  or  who  has  some  other 
gross  handicap,  is  placed  at  certain  occupations,  he  is  liable  to  injure 
himself  or  to  cause  accidents  to  others.  Or,  if  a  man  is  mentally 
deficient,  it  isn't  safe  either  for  himself  or  for  others,  to  allow  him 
to  run  an  engine.  These  are  examples,  however,  of  how  certain 
physical  or  mental  conditions  in  an  employee  can  cause  accidents. 


H,r.-  «.■  lu.v..  .,n  i,  liirR.r  .».:,1,.  r,|.r.«l.i.-li..a.  . 

^;lV,■.i..l•.■„ri.,tl,.■y,,;.rll,,■«,•ar.•^.      Tl,.- .rn  „«!  I,  „l  1 1,,-,- kI,,,-,- w  ,|„m„ 

I  U-t  „,.,l„.  „,„l,|l,-  p„  ,ur,-.     Tl ,  ,„-  .r,.  >..„„  >0,, ,„,,|  ,„  „,,.  fr„,„ 

thr  orifiiKil,.  „.  thill  Ihi-  pi,-,-,-  ..f  ^l.-,-l  „.n,  „,-(„;, ll>  -,i,„-«l,;,l  l:,ri:,-r  tlum  Is 
M„.>v„i„,l„.,-„t       Tl„-mi,„,vl,„«„r,.ll„-lw,ll,„„,.:,ir,v„„l,ll,:,v,-l„.ttmth        ' 

L_;;i;;^, -:"""" "'  ""  ■     "' '""""'"'  '"■ '"" '-"" "" *"'  ''>■  ""ij;^ 

Fig.  44. — A   poster   which   should    be   displayed   wherever   goggles   for   employees 
are  required.      (Courtesy  General  Electric  Co.) 


It  is  in  this  field  that  the  surgeon  deahng  with  accident  prevention 
can  render  some  of  his  most  effective  service  to  an  industry.  While 
these  gross  defects  are  evident  as  hazardous  conditions,  yet  there  are 
many  other  things  which  may  exist  in  employees,  making  them 
"accident  carriers,"  that  only  an  experienced  physician  is  able  to 
discover. 

Just  as  the  frequent  inspection  of  the  physical  conditions  of  the 
plant  is  necessary  to  prevent  accidents,  so  is  the  frequent  inspection 
of  the  employees  essential  to  discover  these  physical  and  mental  causes 


ACCIDENT   PREVENTION  329 

for  accidents.     Here  is  one  of  the  strongest  reasons  for  the  Supervision 
of  Employees  by  medical  examinations. 

Every  employee  sustaining  an  accident,  except  perhaps  the  minor 
accidents  where  the  cause  is  obvious,  should  be  thoroughly  examined 
to  discover  if  any  condition  existing  in  him  might  be  the  active  or 
predisposing   cause. 

When  examining  applicants  for  work,  or  when  examining  an  old 
employee,  the  doctor  should  constantly  be  on  the  lookout  for  potential 
causes  of  accidents  in  the  men.  An  employee  with  some  physical 
handicap  may  be  doing  work  dangerous  for  him,  but  the  doctor  can 
recommend  his  transfer  to  another  occupation  where  he  will  be  efficient 
and  yet  not  be  in  danger  of  an  injury. 

For  example,  Mr.  A,  an  apoplectic  type,  short,  fat,  and  with  flushed 
face,  was  examined.  His  heart  was  slightly  enlarged  and  his  blood-pres- 
sure was  200  mm.  He  felt  perfectly  well  and  was  able  to  work.  But 
his  work  consisted  of  sawing  lumber  on  a  large  circular  saw.  The 
saw  was  protected  yet  if  this  man  had  fallen  he  might  have  been  torn 
to  pieces.  This  was  a  hazardous  occupation  because  of  his  physical 
condition.  A  transfer  was  recommended  by  the  doctor,  and  he  was 
given  the  job  of  measuring  and  sorting  lumber  at  the  same  wage. 
Two  weeks  later  while  at  work  he  had  a  stroke  of  apoplexy. 

An  employee  with  epilepsy,  or  with  a  pathological  condition  liable  to 
make  him  fall,  as  for  instance  apoplexy,  heart  disease,  uremia,  cerebro- 
spinal syphilis,  etc.,  should  never  be  allowed  to  work  about  machinery, 
on  elevations,  or  in  other  places  where  he  could  be  seriously  injured 
by  falling.  Such  a  man  may  be  a  potential  cause  of  accidents 
to  others. 

The  hit  and  miss  method  of  placing  men  on  jobs  without  a  physical 
examination  to  ascertain  their  fitness  for  the  work  makes  accidents 
from  these  causes  much  more  frequent. 

Epileptics  are  very  hard  to  discover  by  examination.  A  history  of 
attacks  or  actually  seeing  the  attack  are  our  only  means  of  diagnos- 
ing this  condition.  Therefore,  these  cases  often  become  accident 
hazards.  Whenever  an  employee  is  suspected  of  or  found  to  have 
epilepsy,  the  surgeon  should  carefully  study  his  working  conditions 
and  recommend  transfer  to  such  work  as  will  be  safe.  Many  in- 
dustries refuse  to  allow  epileptics  to  remain  in  their  employ  because 
of  this  danger  of  falling  and  subsequent  injury.  The  state  care  of 
epileptics  with  outdoor  employment  and  proper  attention  to  diet  and 
other  habits  is  one  of  the  most  needed  social  reforms  of  to-day. 
Many  a  sufferer  from  this  disease  could  be  reclaimed  by  a  proper  regime 
of  work  and  care. 

Mr.  B,  a  new  employee  m  a  printing  plant,  had  been  examined 
for  work  and  found  O.K.       A  week  later  he  fell  in  a  fit  of  epilepsy, 


330  INDUSTRIAL   MEDICINE    AND    SURGERY 

striking  his  head  against  the  printing  press,  and  suffering  a  skull 
fracture.  The  loss  to  the  concern  amounted  to  several  thousand 
dollars.  Four  people  subject  to  epilepsy  were  employed  in  other 
departments  of  this  plant.  The  concern  cannot  be  censured  because 
they  immediately  discharged  these  other  men  who  were  liable  to  fall 
and  cause  an  equal  loss.  The  state,  however,  can  be  blamed  for  not 
providing  some  place  where  these  men  could  go  for  treatment  and 
work. 

Mr.  C,  a  ten  year  employee  in  a  certain  plant,  who  had  been 
periodically  examined  a  number  of  times,  reported  to  the  doctor's  office 
with  a  scalp  wound.  He  stated  that  a  box  had  fallen  from  a  shelf  and 
struck  him  on  the  head.  There  had  been  no-  witnesses.  Two  weeks 
later  Mr.  C  reported  again  with  a  slight  contusion  on  his  cheek  and 
a  lacerated  wound  of  the  nose.  This  was  due  to  a  fall  which  resulted 
from  tripping  on  a  loose  board,  according  to  his  statement.  Again 
there  had  been  no  witnesses.  Some  weeks  later  this  man  again  came 
to  the  doctor  with  another  scalp  wound.  He  claimed  that  he  had 
fallen  down  stairs  but  no  one  had  seen  him  fall. 

This  man  was  given  an  examination  which  was  negative.  An 
investigation  in  his  department  revealed  the  fact  that  an  employee 
had  seen  him  fall  while  in  the  wash  room.  When  the  man  was  con- 
fronted with  this  statement  he  confessed  that  he  had  fallen  while 
standing  in  the  wash  room  but  didn't  know  what  caused  it. 

The  examination  was  then  repeated  and  included  all  laboratory 
tests.  These  were  again  negative  even  to  the  Wassermann  test  on 
his  blood.  By  this  time  the  man  had  confessed  to  falling  frequently 
due  to  "faints"  and  that  his  other  injuries  were  due  to  these  attacks. 
On  account  of  this  history  a  spinal  puncture  was  made  and  the  spinal 
fluid  gave  a  strong  Wassermann  reaction.  The  man  was  suffering 
from  cerebrospinal  syphilis  causing  epileptiform  attacks. 

During  one  year  the  writer  found  three  cases  of  cerebrospinal 
syphilis  in  the  same  industry.  Two  suffered  injuries  due  to  falling. 
The  third  had  been  diagnosed  as  lead  poisoning  by  his  family  physician 
because  the  man  was  a  painter.  A  thorough  study  of  these  cases 
will  reveal  the  cause  of  the  accident,  and  often  of  the  occupational 
disease,  to  be  due  to  the  physical  condition  of  the  employee. 

Dr.  James  Bordley  reports  a  death  and  a  serious  accident  in  a  steel 
mill  from  an  overhead  crane,  both  the  result  of  defective  vision  in  the 
operator  of  the  crane.  This  man  was  given  a  thorough  examination 
and  his  vision  was  found  so  defective  that  the  man  had  no  idea  of 
perspective. 

A  man  with  serious  heart  disease  was  allowed  to  operate  a  dummy 
engine  in  a  mine.  His  heart  failure  and  sudden  death  resulted  in  injury 
to  several  employees  who  were  in  the  cage  being  hoisted  by  this  engine. 


ACCIDENT   PREVENTION  331 

Innumerable  cases  of  injury  to  the  individual,  or  to  others  for 
whose  safety  the  individual  is  responsible,  could  be  related  due  to 
some  condition  in  the  employee,  but  these  examples  suffice  to  point 
out  the  lesson. 

The  third  etiological  group  of  industrial  accidents  are:  those  due  to 
disaster. 

Of  all  disasters  fire  causes  more  accidents  than  any  other. 
Therefore,  the  prevention  of  fires  is  one  of  the  most  logical  forms  of 
preventive  surgery  with  which  the  doctor  can  become  associated. 
It  is  characteristic  of  our  profession's  shortsightedness  that  doctors 
as  a  rule  have  never  considered  it  their  duty  to  enter  into  a  campaign 
for  fire  prevention.  We  have  reduced  disease  by  public  sanitation 
but  we  have  not  put  this  same  humanitarian  effort  into  the  prevention 
of  accidents  to  the  public. 

Every  industry  has  or  should  have  its  fire  brigades,  fire  drills,  rules 
for  prevention  of  fire  and  means  of  escape  for  the  employees  in  case  of 
fire.  It  is  one  of  the  duties  of  the  plant  surgeon  to  point  out  these 
needs  and  to  improve  in  every  way  these  methods  of  prevention. 

The  National  Safety  Council  has  added  a  section  on  Fire  Prevention 
to  its  organization.  The  transactions  of  this  section,  obtainable  from 
this  Association,  are  worth  the  study  of  all  doctors  and  especially  of 
industrial  surgeons. 

Specialized  industries  will  have  their  special  dangers  for  disaster. 
The  surgeon  must  familiarize  himself  with  these  and  make  certain 
that  proper  precautions  are  taken  at  all  times  to  safeguard  the 
employees. 

MINOR  ACCIDENTS 

The  same  preventive  measures  outlined  for  major  accidents  are 
applicable  to  many  minor  accidents.  However,  every  surgeon  con- 
nected with  industry  has  found  it  most  difficult  to  prevent  a  large 
majority  of  these  minor  injuries. 

As  a  rule,  a  slight  injury  never  causes  any  suffering  to  the  employee 
nor  any  lost  time  from  work  with  its  corresponding  loss  of  wages. 
Likewise,  minor  injuries  occur  so  frequently  to  every  worker  that  he 
becomes  accustomed  to  them.  These  two  facts  make  the  prevention 
of  minor  accidents,  and  the  prevention  of  complications  when  they 
do  occur,  very  difficult. 

An  employee  will  get  a  splinter  in  his  finger  time  and  again.  He 
removes  it  himself  or  gets  some  fellow  employee  to  remove  it.  No 
trouble  ever  results.  But  the  hundredth  splinter  results  in  a  serious 
hand  infection.  It  is  often  impossible  to  explain  why  all  the  other 
splinters  were  harmless  and  this  particular  one  caused  the  trouble. 
For  this  reason  it  is  hard  to  make  the  workman  take  proper  precau- 


332  INDUSTRIAL    MEDICINE    AND    SURGERY 

tions  with  the  ninety-nine  spUnters  in  order  to  prevent  the  hundredth 
one  from  starting  an  infection. 

Nevertheless,  the  prevention  of  comphcations  from  these  Httle 
daily  injuries  depends  upon  treating  everyone  at  once  as  a  potential 
trouble  maker. 

Examples  of  minor  injuries  that  are  almost  impossible  to  prevent 
and  yet  frequently  result  in  serious  complications,  are: 

Dust,  cinders,  etc.,  flying  in  the  eyes. 

*' Barking"  the  skin  on  tools,  machines,  boxes  and  other  objects. 

Hang  nails,  often  due  to  the  work. 

Pin  pricks — ^commonest  in  girls. 

Wounds  from  splinters,  nails  and  other  penetrating  objects. 

Scratches  or  slight  lacerations  from  nails,  loose  wire,  loose  boards, 
paper,  and  a  thousand  other  objects  with  which  the  employee  may 
come  in  contact. 

Contusions  from  falling  objects,  striking  the  finger  with  a  hammer, 
being  bumped  by  a  door,  and  other  innumerable  ways. 

Slipping  on  the  floor,  tripping,  and  other  unaccountable  causes 
for  falls. 

From  early  childhood  we  have  been  receiving  such  injuries  as  these 
and  only  occasionally  has  some  trouble  followed.  It  is  almost  sec- 
ond nature  to  pay  no  attention  to  them.  Therefore,  it  takes  years 
of  patient  endeavor  to  educate  a  group  of  employees  to  take  pre- 
cautions when  such  unpreventable  accidents  occur. 

These  minor  accidents  must  be  combated  by  preventing  compli- 
cations from  developing,  as  well  as  by  teaching  employees  the  "art 
of  being  careful." 

In  1912  the  author  published  the  results  of  preventing  infec- 
tions among  employees  due  to  these  miner  injuries.  For  the  six  months 
previous  to  January  15,  1909,  the  records  of  the  doctor's  office  showed 
an  average  of  twenty-six  infections  per  month  due  to  minor  accidents. 
On  that  date  every  department  was  supplied  with  a  bottle  of  tincture 
of  iodin  and  another  bottle  containing  applicators  (cotton  rolled  on 
a  toothpick).  A  letter  instructing  each  employee  to  paint  at  once 
with  iodin  every  wound  received,  which  broke  the  skin,  was  sent  to 
every  man  and  woman  in  the  plant.  The  managers  were  carefully 
instructed  in  the  value  of  this  procedure  and  kept  a  careful  watch 
over  the  employees  to  see  that  they  observed  the  rule.  A  daily  in- 
spection was  made  to  see  that  the  iodin  bottles  were  filled  and  ready 
for  use.  Immediately  these  infections  began  to  diminish.  At  the 
end  of  the  year  the  records  showed  an  average  of  eight  such  cases  per 
month,  a  reduction  of  28  per  cent. 

Many  of  these  cases  of  infection  which  developed  should  have 
reported  to  the  doctor  but  they  thought  the  iodin  treatment  alone 


ACCIDENT    PREVENTION 


333 


made  this  unnecessary.  Therefore,  we  had  to  add  to  our  instructions 
the  immediate  use  of  iodin  and  then  the  immediate  reporting  to  the  doc- 
tor's office  no  matter  how  slight  the  injury.  The  importance  of  this 
preventive  measure  is  further  emphasized  in  the  chapter  on  Hand 
Infections  (Fig.  45). 

Some  industries  may  have  used  iodin  previous  to  the  pubUsh- 
ing  of  this  article  but  these  were  the  first  pubhshed  statistics  on  the 
results.  This  procedure  soon  became  quite  universal  in  industrial 
surgery.     Those  who  fail  to  get  the  best  results  fail  to  provide  tinc- 


FiG.  45. — Blood  Poisoning. 

John  Doe  of  department  4  scratched  his  hand  on  a  nail.  He  failed  to  paint  the 
wound  with  iodin  and  to  report  to  the  doctor's  office  at  once.  He  didn't  think  such  a 
alight  scratch  would  amount  to  anything.  To-day  John  is  in  the  hospital  with  blood 
poisoning. 

On  all  injuries,  no  matter  how  slight,  use  iodin  at  once  and  report  to  the  doctor  at  once. 
Example  of  educational  bulletin  posted  in  all  departments. 

ture  of  iodin  in  a. convenient  form  and  in  a  place  easily  accessible  to 
all  employees.  To  be  100  per  cent,  effective  it  must  be  used 
within  two  minutes  after  injury.  Also  to  be  100  per  cent,  effective  it 
should  be  followed,  as  soon  as  the  employee  can  reach  the  doctor, 
with  a  protective  dressing.  It  is  impossible  to  say  which  of  these  is 
the  most  important  but  combined  we  have  the  ideal  arrangement. 

Some  doctors  have  discarded  iodin,  which  heretofore  has  proven  our 
best  friend,  since  the  Carrel-Dakin  treatment  has  received  so  much 
attention.  As  Dr.  Lauffeur  of  the  Westinghouse  Company  so  forci- 
bly pointed  out — -"iodin  has  proven  its  value  and  is  the  best  prevent- 
ive  measure   we   have   yet   discovered   for   infections."     This   in   no 


334  INDUSTEIAL   MEDICINE    AND    SURGERY 

way  refutes  the  claims  of  the  Carrel-Dakin  solution  as  a  treatment 
agency. 

The  protection  of  hands  by  gloves,  of  the  eyes  by  goggles,  of  the 
legs  and  arms  by  asbestos  covering  when  slight  burns  are  liable  to 
occur,  and  other  protective  methods  can  be  adopted  in  many  industries 
to  reduce  these  slight  accidents. 

But  the  best  method  of  preventing  both  major  and  minor  accidents 
is  by  constantly  instructing  employees  how  to  prevent  accidents, 
how  to  prevent  a  recurrence  of  an  accident,  and  how  to  prevent  com- 
phcations  from  developing  when  an  accident  has  occurred.  Com- 
bined with  this  there  must  be  the  most  active  treatment  of  every 
injury  from  the  very  moment  it  occurs  until  it  is  cured  by  a  surgeon 
skilled  in  emergency  surgery. 

The  spirit  of  prevention  must  be  developed  in  the  management, 
in  the  rank  and  file  of  the  employees,  and  in  the  medical  staff,  in  order 
to  have  an  efficient  human  maintenance  department. 


CHAPTER  XXII 
THE  SPIRIT  OF  PREVENTION 

In  this  country  accident  prevention  is  still  in  its  infancy.  It 
started  with  a  few  laws  requiring  the  safeguarding  of  a  few  certain 
well  known  hazards.  Gradually  a  few  industries  began  to  safeguard 
machinery  by  safety  appliances.  This  finally  led  to  the  Safety  First 
movement  inaugurated  by  the  National  Safety  Council — a  volunteer 
organization.  Their  work  in  the  beginning  consisted  of  the  instal- 
lation of  every  known  device  for  preventing  accidents.  The  American 
Museum  of  Safety,  established  several  years  ago,  was  among  the  first 
to  do  excellent  work  along  this  line  by  its  exhibits  of  safety  devices. 

These  and  other  safety  movements  starting  with  the  mechanical 
prevention  appHances  all  came  to  the  same  conclusion,  namely, 
that  while  these  are  necessary  yet  the  majority  of  accidents  were  due 
to  the  ignorance  and  carelessness  of  individuals.  Therefore,  to  secure 
the  greatest  results,  educational  campaigns  on  Accident  Prevention 
must  be  started  and  made  universal. 

In  some  countries  such  as  Switzerland,  Germany,  and  to  a  certain 
extent  in  England,  accident  prevention  has  long  been  a  national  prob- 
lem. The  governments  have  their  official  experts  studying  the 
problem  from  every  angle.  New  laws  increasing  the  safety  of  the 
working  people  are  enacted  almost  every  year.  Inspectors  to  in- 
vestigate and,  mark  you,  to  enforce  the  laws  are  in  the  field.  And 
the  money  paid  out  in  compensation  makes  both  employer  and  em- 
ployee more  anxious  to  reduce  the  number  of  accidents.  In  addition, 
the  school  children  are  taught  accident  prevention  and  the  colleges 
and  universities  give  courses  on  this  subject.  Every  means  to  en- 
gender a  national  spirit  of  prevention  is  used. 

The  ''Stop,  Look  and  Listen"  sign  at  railroad  crossings  was  the 
first  educational  propaganda  for  accident  prevention  ever  introduced 
on  a  universal  scale  in  this  country.  During  the  last  decade  the 
use  of  signs  or  bulletins  as  a  means  of  spreading  the  gospel  of  pre- 
vention has  become  very  popular.  All  kinds  of  signs  are  posted  in 
trains,  street  cars,  and  in  many  industries,  pointing  out  the  means  to 
avoid  injuries. 

In  a  few  states  the  Departments  of  Industry  and  Labor,  or  the 
Industrial  Boards,  or  the  State  Factory  Inspector's  Office  have  made 
the  spread  of  this  prevention  propaganda  one  of  their  duties. 

335 


336 


INDUSTRIAL    MEDICINE    AND    SURGERY 


One  of  the  best  examples  is  furnished  by  the  State  of  Pennsylvania 
Department  of  Industry  and  Labor  under  Commissioner  John  Price 
Jackson  and  his  assistant,  now  acting  Commissioner,  Mr,  Lew  R. 
Palmer.  They  have  formed  a  corps  of  experts  on  disease  and  accident 
prevention  and  the  medical  phase  of  the  work  is  under  the  direction 
of  Dr.  Francis  Patterson.  While  stimulating  the  use  of  every  known 
safety  appliance,  yet  they  have  found  that  the  greatest  results  come 


ACCIDENT  PREVENTION  POSTIR 


Number  17 


EVERY 


person  who  pays  no  attention  to  the 


UTTLE 


cut  or  scratch  may  think  that  there  is  no  dzuiger 
from  such  a  little 


BIT 


of  a  wound.      Accident  reports  show^,  hoivever,  that 

those  cU'e  the  ones  from  which  blood 

poisoning  usually  develops. 


FIRSI  AID  TREATMENT 

HELPS 


to  stop  deaths  from  this  cause. 
DOirr  FAIL  TO  HAVE  MINOR  INJURIES  ATTENDED  TO  AT  ONCE 


COMMONWEALTH  OF  PENNSYLVANIA 

DEPARTMENT  OF  LABOR  AND  INDUSTRY 

JOHN   PRICE  J&CK20N.  Commi..ianer 


Fig.  46. — Placards  which  spread  the  spirit  of  prevention. 

from  educational  campaigns.  Below  are  two  examples  of  the 
placards  which  are  freely  circulated  to  every  industry  throughout  the 
state,  to  be  posted  in  conspicuous  places  for  the  education  of  their 
employees  (Figs.  46  and  47). 

Ohio,  Massachusetts,  New  York,  California,  and  a  few  other 
states  to  a  lesser  degree,  have  adopted  this  method  of  instructing 
workmen.  It  is  applicable  to  the  prevention  of  occupational  diseases 
and  many  other  diseases.     It  should  be  used  more  extensively. 

In  order  to  secure  the  co-operation  of  employers,  workmen,  safety 
engineers  and  plant  physicians.  Dr.  Patterson  organized,  some  two 


THE    SPIRIT    OF    PREVENTION 


337 


years  ago,  the  Pennsylvania  Chapter  of  the  American  Association 
of  Industrial  Physicians  and  Surgeons,  and  invites,  three  times  a  year, 
representatives  of  all  four  of  these  groups  to  meet  in  joint  session  at  the 
State  Capitol  to  discuss  both  accident  and  disease  prevention. 

The  American  Association  of  Industrial  Physicians  and  Surgeons 
are  making  efforts  to  persuade  every  state  in  the  union  to  adopt  a 
similar  plan. 


ACCIDENT  PREVENTION  POSTER 


Number  18 


THE 

country  just  now  needs  the  services  of  all 

GOOD 

workmen.     It  wants  every  one  to  live  to  a  ripe 

OLD 

age.     Avoid  dangerous  methods— do  your  work  carefully 
and  skillfully  and  thus  do  your  bit  for  the 

U.S.  A. 


COMMONWEALTH  OF  PENNSYT-VANIA 

DEPARTMENT  OF  LABOR  AND  INDUSTRY 


JOHN  PRICE  JACKSON,  CommUuone* 


Fig.  47. — Placard  which  serves  a  double  purpose — prevention,  efficiency. 

In  some  states  the  manufacturing  associations  have  quarterly 
meetings  to  discuss  these  safety  methods.  As  a  result  many  employers 
have  adopted  the  educational  plans  for  prevenbion  advocated  by  the 
National  Safety  Council. 

In  some  cities  the  Associations  of  Commerce  have  rendered  ex- 
cellent service  in  teaching  accident  prevention.  The  Rochester, 
New  York,  Chamber  of  Commerce  has  been  very  active  in  both 
disease  and  accident  prevention  among  the  city's  industries.  Reahz- 
ing  that  education  must  begin  in  the  home  they  prepared  a  pamphlet 
and  circulated  it  throughout  the  homes  of  the  city.  The  following  is 
quoted  from  this  pamphlet: 


338  INDUSTRIAL    MEDICINE    AND    SURGEEY 

"  ACCIDENTS  IN  THE  HOME" 

"It  is  a  peculiar  thing  that  accident  insurance  companies  find 
that  the  bath  tub  is  responsible  for  the  largest  number  of  accidents 
that  occur  in  the  home. 

''  On  first  thought  it  seems  extraordinary  that  this  agent  of  clean- 
liness should  have  destructive  features,  but  the  number  of  people 
who  slip  in  one  way  or  another  and  fracture  arms  or  legs  or  inflict 
minor  injuries  upon  themselves  in  this  way  is  surprising. 

"Falling  down  stairs  is  the  next  most  favored  method  of  inflicting 
injury  upon  oneself.  It  is  true  that  the  stairways  in  homes  are  not 
so  well  lighted  as  those  in  office  buildings,  stores  or  factories,  but  it 
would  seem  that  this  lack  of  light  ought  to  be  more  than  balanced 
by  the  greater  familiarity  people  would  have  with  their  own  stairways. 

"  The  high  heeled  shoe  is  responsible  for  many  falls  both  in  and  out 
of  the  house,  but  it  is  especially  dangerous  on  stairways  where  the  edge 
of  the  heel  catches  and  trips  the  wearer  into  a  headlong  fall. 

"  Burns,  scalds  and  fires  in  the  kitchen  are  responsible  for  much  in 
the  list  of  accidents.  These  occur  either  through  carelessness  or 
ignorance  of  conditions. 

"  The  tea  kettle,  half  full  of  boiling  water,  is  taken  to  the  sink  to  be 
filled,  the  top  removed,  the  water  turned  on  and  the  hand  kept  on  the 
handle.  The  steam  may  cause  her  to  drop  the  kettle,  thus  spilling 
the  boiling  water  upon  her. 

"^^  The  grease  employed  in  cooking  some  kinds  of  food  is  a  source 
of  danger  because  it  both  spatters  and  takes  fire  after  being  heated 
above, a  certain  point.  Burning  grease  is  very  dangerous  and  burns 
deep  into  the  flesh  and  the  wounds  heal  slowly.  Should  the  grease 
take  fire  it  is  extremely  difficult  to  extinguish  the  blaze. 

"  Persons  who  pull  down  shelves  upon  themselves,  drop  heavy 
weights  upon  their  feet  or  inflict  painful  cuts  by  axes  or  hatchets,  are  in 
a  class  by  themselves.  The  danger  is  specific  in  every  respect  and  it 
is  for  the  most  part  a  thankless  task  to  impress  upon  them  general  rules 
of  carefulness;  in  other  words,  it  is  useless  to  suggest  methods  of  doing 
things  that  should  suggest  themselves. 

"  It  can  be  taken  as  a  fact  that  accidents  in  the  home  are  due  to  the 
fundamental  causes,  haste  and  carelessness. 

"  Will  you,  gentle  reader,  turn  your  attention  upon  yourself  and 
upon  these  quotations?  'If  the  telephone  or  door  bell  rings,  do  you, 
in  your  haste  to  answer,  endanger  your  life  on  the  stairway  or  on  rugs 
or  waxed  floor  ?  ^  'Do  you  mingle  caution  with  your  hastie  ? '  *  Do  you, 
as  you  go  through  your  daily  routine,  remember  that  it  is  just  as 
important  to  do  each  thing  carefully  as  it  is  to  get  the  thing  done?' 

"If  by  neglecting  precautions  for  your  safety  and  the  safety  of 
others  you  increase  the  cost  of  living  by  breaking  bones,  straining 


STANDARD  SAFETY  ORGANIZATION  INSPECTION  AND  EDUCATION  CHART 


A  SUPERVISOR  OF  SAFETY 
WORK  (employer,  member  of  firm, 
manager,  superintendent  or  foreman 
in  charge)  who  shall: 

1.    Review  and  approve  inspcciion 
reports  and  safely  suggestions. 


A  GENERAL 

Manager,  Superi 

(1)  Meet  ai 

(2)  Review 


t  monthly  and 


.  less  than  three  persons  shall  be  selected  from  the  following; 

Master  Mechanic,  Foreman  or  other  employee  in  a  position  of  agthority  and  shall: 

pass  on  all  recommendations  to  determine  their  practicability  and  desirability,  and  keep  records  of  i 


(3)  Familiarize  themselves  with  tl 

(4)  See  that  rexv  employees  are  [ 
practices  through  the  use  of  b 

(5)  Supervise  the  safety  inspect!© 


A  WORKMEN'S  COMMITEE  consisting  of  at  I 

changed  at  regular  intervals,  preferably  by  rotation,  and  the 

(1)     Make  not  less  than  one  thorough  inspection  of  the  plant  each 


workmen.     The  personnel  of  the  ( 


en  reports  of 
'  ttie  general 


va|s,  preferably  by  rotation,  and  the 

(I)  Make  at  ieast  one  general  inspection  of  the  plant  and  hold  at  least  one 
meeting  every  three  months  for  the  purpose  of  standardizing  safety 
work  throughout  the  plant. 


A  SAFETY  INSPECTOR,  who  shall  be  a  competent  person  in  charge  of  inspection  s 


1  shall: 


A  SAFETY  ENGINEER  who  shall 
devote  at  least  one-half  of  his  entire 
time  to  safety  and  inspection  work  and 
who  shall . 


A  SAFETY  ENGINEER  who  shall 
inspection  work  and  who  shall: 


(1)  Make  tegular  weekly  inspection  ot  the  plant. 

(2)  FUi  out  and  sign  weekly  reports  showing  conditions  of  the  plant  and  recommendations  tor  changes, 

(3)  Keep  these  reports  on  file  in  the  office  tor  review  by  general  committee,  state  authorities-  and  insurance  safety  precai 
carriers,    (Standard  blanks  are  furnished  by  insurance  carriers  for  this  purpose.)                                                                          (3)     Keep.complete  reco 

(4)  Follow  up  general  lines  of  outstanding  safety  work  and  keep  records  of  same,  which  indicate  progress. 

(5)  Make  or  arrange  ior  regular  inspections  of  special  equipment,  such  as  elevators,  cranes,  engine  and  mot^ 
each  inspection, 

(6)  Look  after  fire  conditions,  extinguishers,  filling  of  fire  pails  (water  and  sand)  and  keeping  exits  clear. 

(7)  ,  Sec  that  drawings  and  specifications  for  new  equipment  cover  the  guarding  of  dangerous  features  such 


Is  required  herein. 

■  stops,  etc.,  and  keep  ^ 


conductors,  ( 

(8)  Inspect  new 

(9)  Investigate  a 


nachinery  before  placed  in  operation  to  : 
id  report  to  general  committee  on  all  ace 
^^^^^^  (10)     Inspect  for 


and  lighting  and  for  obediei 


that  necessary  safeguards  a 
safeguards,  g 


gears,  sprockets,  coupli 
provided, 
cral  order  and  arrange; 


if  materials  and  stock,  cleanirnk^ss 


1  which  safety  bulletins  (which  shall  be  changed  at  least  mc 

,le  a  RECORD  OF  ALL  ACCIDENTS  by  preserving  duplicates  c 

'' 1        QUARTERLY  MEETINGS  of 

not  be  provided  tor  these  meetii 


Ihly)  safety  orders,  r 


mation  shall  be  posted, 
furnished  by  state  depa 
safety  shall  be  given.    E 


SAFETY  LITERATURE  such  as  operatir 
ganda,  etc.,  which  should  be  distributed  t 
magazines,, pay  envelopes,  or  special  bullet 


Fig.  48. — (Courtesy  of  the  National  Manufacturers  Asaociatioa). 


THE    SPIRIT   OF   PREVENTION  839 

muscles,  burning  the  flesh,  to  say  nothing  of  the  cost  of  replacing 
destroyed  utensils  and  equipment,  are  you  making  yourself  the  best 
possible  housekeeper  ? ' ' 

Recognizing  that  accident  prevention  depends  upon  Inspection 
and  Education  the  National  Association  of  Manufacturers  has  been 
very  active  in  stimulating  employers  to  adopt  these  two  means  of 
protecting  the  lives  and  limbs  of  their  employees.  They  have  pre- 
pared a  plan  for  a  standard  safety  organization  which  is  now  being 

"    ■  '    '    ?^ 

■  i 

Your  Eves 


Are  your  most  valuable  asset. 

!  he  above  eye  was  saved  by  the  goggles. 

Duiinijthe  mpnth  of  May  33  Vj  per  rent  of 
all  major  accidents  were  eye  cases  beside 
89  minor  cases. 

Protect  your  eyes  from  flying  chips  and  em- 
ery chi.st. 

Ask  your  loreman  for   a  pair  of  jioggles  and 


Save  Your  Eyes     I 

_..  ..:_ ^ 


Fig.  49. — Example  of  anti-accident  propaganda  among  the  employees  of  the  General 

Electric  Co. 

followed  to  a  certain  degree  by  many  manufacturers.  Those  who 
enthusiastically  endorse  this  plan  have  secured  wonderful  results 
because  they  have  adopted  it  in  toto.  Others  have  only  half- 
heartedly installed  this  system  and  therefore  have  not  succeeded  in 
reducing  their  accidents  to  as  great  an  extent.  In  this  work  the  re- 
sults are  in  direct  ratio  to  the  thoroughness  of  the  plan  in  force. 

As  surgeons  should  be  the  leaders  in  estabhshing  this  form  of 
prevention  in  their  industries  this  standard  safety  plan  of  the  National 
Manufacturers'  Association  is  set  forth  in  detail  (Fig.  48). 

The  fact  that  compensation  underwriters  make  a  15  per  cent, 
reduction  in  premiums  in  those  industries  where  this  standard  safety 
organization  is  installed  and  rigidly  enforced,  indicates  in  a  way  the 


340  INDUSTRIAL    MEDICINE    AND    SURGERY 

monetary  value  of  this  form  of  prevention.  It  is  impossible,  however, 
to  set  forth  in  dollars  and  cents  the  great  saving  to  employers,  or 
the  increased  earning  capacity  from  enlarged  production  which  this 
or  any  other  form  of  accident  prevention  means  to  a  concern. 

The  National  Manufacturers'  Association,  30  Church  Street,  New 
York,  has  secured  one  thousand  lantern  slides  illustrating  safety 
first  methods,  as  well  as  numerous  motion  picture  reels,  which  it  will 
furnish,  free  of  charge,  to  those  industries  desiring  to  hold  meetings  for 
their  employees  on  accident  prevention  work. 

The  National  Safety  Council,  the  American  Museum  of  Safety, 
the  United  States  Department  of  Labor,  and  many  of  the  leading 
industries  of  the  country  are  all  very  willing  to  supply  material  for 
educational  campaigns  on  safety.  Among  those  industries  which 
have  excellent  material  for  instruction  purposes  are  the  United  States 
Steel  Corporation,  the  General  Electric  Company,  the  International 
Harvester  Company,  the  Brooklyn  Rapid  Transit  Company,  and 
others. 

The  Conference  Board  on  Safety  and  Sanitation,  of  which  Mr. 
Magnus  W.  Alexander  of  West  Lynn,  Mass.,  is  Executive  Secretary, 
publishes  a  monthly  periodical  called  "The  Spirit  of  Caution"  which 
is  of  the  greatest  value  to  surgeons  and  others  interested  in  spreading 
accident  prevention  material. 

Mr.  R.  J.  Young  of  the  American  Museum  of  Safety  has  set  forth 

the  relative  value  of  the  various  forms  of  safety  work  employed  by 

the  Illinois  Steel  Corporation  during  a  period  of  ten  years.     He  has 

.  divided  their  safety  work  into  three  branches  and  estimates  the  value 

of  each  as  follows: 

I.  Organization 45  per  cent. 

(a)  Attitude  of  officers 20  per  cent. 

(6)   Safety  committees 20  per  cent. 

(c)    Inspection  work 5  per  cent. 

II.  Education 30  per  cent. 

(a)  Instruction  of  men 15  per  cent. 

(b)  Prizes 9  per  cent. 

(c)  Posting  of  signs 3  per  cent. 

(d)  Lectures,  motion  pictures,  etc 3  per  cent. 

III.  Safeguarding 25  per  cent. 

(a)  Guards 17  per  cent. 

(6)  Lighting 5  per  cent. 

(c)   Cleanliness 3  per  cent 

Since  organizing  the  safety  committees  and  securing  the  proper 
attitude  of  the  officers  toward  the  work  is  largely  educational,  it  is 


THE    SPIRIT    OF    PREVENTION  341 

quite  apparent  that  at  least  70  per  cent,  of  the  success  in  safeguarding 
employees  against  accident  is  the  result  of  well  organized  educational 
campaigns  against  these  accidents. 

It  is  quite  evident  that  unless  the  officers  of  an  industry  V)ecome 
personally  interested  in  accident  prevention  progress  in  the  work  will 
be  very  slow.  Those  concerns  which  are  the  farthest  advanced  in 
the  safety  movement  and  whose  employees  have  acquired  the  spirit 
of  prevention  to  the  highest  degrees  are  the  ones  in  which  the  president 
or  other  executive  members  of  the  industry  have  taken  an  active 
part  in  the  work.  They  have  become  associated  with  the  National 
Safety  Council  and  other  such  organizations.  They  attend  the  meet- 
ings in  person  and  by  the  giving  and  taking  of  suggestions  they  become 
thoroughly  imbued  with  the  ideals  of  "Safety  First."  Such  men  keep 
in  advance  of  their  medical  staffs  and  safety  engineers  rather  than  haK 
heartedly  following  the  advice  and  suggestions  of  them. 

Of  equal  importance  to  securing  the  co-operation  of  the  employers 
in  such  work  is  to  secure  the  whole-hearted  co-operation  of  the 
employees. 

The  organization  of  safety  committees  among  the  employees  has 
been  a  most  potent  means  of  spreading  prevention  propaganda. 
These  committees  should  be  changed  every  year  so  that  a  few  new 
members  are  added,  thus  increasing  the  number  of  prevention  ex- 
perts throughout  the  force.  Such  committees  receive  suggestions, 
from  the  employees  as  to  means  of  bettering  safety  arrangements; 
they  are  constantly  on  the  lookout  for  potential  accidents;  they  are: 
themselves  the  seeds  of  prevention  from  which  the  great  spirit  of 
prevention  must  grow. 

Qualified  inspectors  of  safety  methods  are  essential  in  every  large* 
plant  where  accidents  are  prone  to  occur.  These  inspectors  can  be 
of  the  greatest  value  to  a  concern  if  their  vision  is  broadened  to  the 
extent  that  they  think  in  terms  of  prevention  from  every  angle  rather 
than  from  the  standpoint  of  safety  appliances  alone.  Thus,  the  in- 
spector who  is  ever  on  the  lookout  for  unsanitary  conditions  in  the 
working  place,  or  for  unhealthy  appearing  employees,  and  has  the 
vision  of  preventing  accidents,  the  result  of  any  cause  in  the  working 
place  or  among  the  workmen  themselves,  is  invaluable  to  his  concern. 
Such  an  inspector  will  welcome  suggestions  from  the  medical  staff 
and  will  work  in  the  closest  co-operation  with  the  doctor.  If  the  safety 
experts  could  better  realize  this,  the  value  of  Mr.  Young's  inspectors 
would  be  25  per  cent,  instead  of  5  per  cent,  as  shown  in  his  table. 

Most  of  the  educational  methods  have  been  described.  However, 
the  use  of  ''prizes"  is  mentioned  in  the  above  outline.  These  prizes 
refer  to  the  method  of  giving  a  bonus,  or  a  prize,  to  that  department 
having  the  lowest  accident  rate — a  plan  adopted  by  several  concerns. 


342 


INDUSTRIAL    MEDICINE    AND    SURGERY 


>- 

- —              ■ 

--^.^^^ 

Z 

^s^ 

< 

\^ 

o 

(L 

\ 

Z 

I 
• 

2 

0        / 

CO            \ 

s    \ 

i 

0 

fc 

< 

:3 

*< 

z 

tu 

m 

a. 

e 

7.        \ 

</> 

tu 

a,          / 

Amou 

< 

\^ 

< 

CO 

<  J 

u 

0 

/ 

i 

Q 

y 

Z 

111 

—       ^ 

--^ 

(0   (I)  4   0   >s 

«I^£S 

d 

J3    .  m  >,  C 

z 

(si 

rto 
are 
help 
e  wa 
ave  1 

o 

DC 

^ 

INGI 

r  helpe 
as  you 
't  be  a 
s  to  th 
may  s 
u. 

i 

BC 

(0 
CM 

> 

VARN 

ct  you 
hanlc 
vouldn 
ation  a 
e  done 
hof  yo 

1 

V 

axpe 
mec 
he  \ 
plan 
to  b 
rbol 

H- 

^           ^ 

Ul 

■^H 

■^^^^■r                                            b   N/   ,.   n 

3C 

IIB 

^■0                                .-^   <«   0   Q  -   0, 

1- 

V^ 

1 

Doti 
good 
Isn't, 
little 
work 
to  on 

CO 


o 

(/)    ft 

I-    «» 

Q.     ti 

u  s 
o  * 
111    3 

a.   's 

>    s 

111       o 

*1  o 

«*' 
n  t» 

.S 


4> 

e 

•£ 

TJ 

<« 

c 

bo 

1 

s 

> 

4> 

(0 

ft 

o 

4m 

0 

4) 

to 

CU  c 

'S  w  2  « 
*',«  c  o 

-^  —  * 
S  *    .  («  B. 

i  0.S 

O    flJ    4> 
4>       * 

a>  ?U4>fl 

.2-n  o  oirt 

•sS:§'S  ft 

-a  M-  'c 
S>€  %{  «  ^ 
.S-g  >  S  2 

S  «  6  a  * 

60?  rt  JS 

;:.£  u  ft 


r     -     "l     O 

"  O  (UJ3 


•o-o 

«>  V 
4)   «) 

X  73 


■s 

10 

in 

c 

Q> 

U) 

0> 

o 

Vi 

o 

n 

•o 

o 

■n 

n 

c 

£ 

n 

5- 

(A 

■o 
n 

3 

4) 

O 

«  ® 
xS 


THE    SPIRIT    OF    PREVENTION 


343 


This  has  been  a  successful  means  of  reducing  accidents  and  has  been 
a  great  incentive  to  the  men  to  be  careful.  The  careless  employee 
who  makes  his  fellow  employees  lose  their  bonus  because  of  his  care- 
lessness doesn't  usually  repeat  the  experiment. 

One  of  the  best  means  of  educating  the  employees  m  safety 
precautions  is  by  short,  terse  statements  or  warnings  printed  on  the 
pay  envelope.  These  envelopes  are  usually  carried  home,  thus  extend- 
ing the  scope  of  their  lessons  to  the  family  as  well.  Many  concerns 
have  employed  this  method  for  disease  as  well  as  for  accident  preven- 
tion.    They  have  developed  their  own  forms  of  advice  and  have  ex- 


Pjq    51._Safety  precepts  taught  by  illuminated  sign  at  works  entrance. 
{Courtesy  U.  S.  Steel  Corporation.) 

changed  with  other  concerns  until  almost  every  angle  of  prevention 
has  been  covered.  The  three  pay  envelopes  herewith  reproduced 
illustrate  this  method  (Fig.  50). 

The  United  States  Steel  Corporation  has  large  illummated  signs 
over  every  gate  leading  into  their  plant.  Every  week  some  new 
safety  advice  is  there  for  the  men  to  read  as  they  go  to  then-  work. 
This  constant  educational  work  is  one  of  the  best  examples  of  an  m- 
dustry  developing  the  spirit  of  prevention  among  its  employees.  The 
following  Ust  of  wordings  used  on  pay  envelopes  and  illummated  gate 
signs  was  furnished  by  the  management  of  the  United  States  Steel 
Corporation  and  is  reproduced  here  for  the  benefit  it  may  be  to  others: 
1.  The  prevention  of  accidents  and  mjuries,  by  all  possible  means, 
is  a  personal  duty  which  everyone  owes,  not  to  himself  alone,  but  also 
to  his  fellow  workmen. 


344  INDUSTRIAL    MEDICINE    AND    SURGERY 

2.  Do  not  get  into  dangerous  places  until  you  are  absolutely- 
sure  they  are  safeguarded;  also  prevent  anyone  from  going  until 
this  is  shown  to  be  a  fact. 

3.  Remember  it  is  better  to  cause  a  delay  than  an  accident. 

4.  Small  neglects  are  apt  to  cause  serious  accidents. 

5.  Let  every  employee  make  himself  a  committee  of  one,  to  prevent 
some  one  accident. 

6.  The  failure  to  obey  safety  rules  endangers  the  life  of  yourself 

or  fellow  workman. 

SAFETY 

7.  It  pays  to  think  before  you  act. 

8.  One  man's  effort  toward  safety  may  seem  small,  but  altogether 
can  do  a  great  deal. 

9.  Every  effort  in  this  direction  helps. 

10.  Be  sure  everything  is  safe;  then  go  ahead. 

11.  Help  to  prevent  accidents. 

12.  Look  out  for  the  other  man,  you  might  hurt  him. 

13.  Try  to  avoid  accidents; 

this  means 
YOU 

14.  Do  not  work  with  unsafe  tools.     Tell  your  foreman. 

15.  Every  injury,  no  matter  how  shght,  should  receive  medical 
attention. 

16.  Never  remove  or  even  touch  a  safety  flag,  tag  or  target. 
Always  get  the  man  who  placed  it  to  remove  same. 

17.  Safety  committees  may  overlook  something.  See  for  yourseK 
that  all  is  safe. 

18.  Do  not  fail  to  notice  all  danger  signs,  and  if  possible,  see  that  no 
one  disregards  them. 

19.  Safety  devices  are  of  little  value  unless  maintained  and  used 
as  they  are  intended. 

20.  Careful  men  are  usually  efficient;  careless  men  are  not. 

21.  Use  safety  devices  where  provided.     Don't  take  a  chance. 

22.  Replace  all  guards  and  safety  devices  when  through  making 
repairs,  and  before  machinery  is  started. 

23.  It  is  your  duty  to  report  unsafe  conditions  to  your  foreman 
or  superintendent. 

24.  Every  sign  in  the  mill  means  that  the  danger  pointed  out  is 
there.     You  must  obey  these  warnings. 

25.  Don't  fool  with  electricity.     It  is  dangerous. 

26.  Look  out  for  loads  carried  by  overhead  cranes  and  do  not  stand 
under  them. 

27.  Employees  are  cautioned  to  look  out  for  torn  clothing  as  same 
is  liable  to  be  caught  in  machinery. 


THE    SPIRIT    OF    PREVENTION  345 

28.  Foremen:  Carelessness  is  dangerous.     If  workmen  insist  on 
being  careless,  discharge  them. 

29.  The  proper  inspection  of  tools  and  machinery  by  employees 
using  same  will  help  to  prevent  accidents. 

30.  The  more  you  insist  upon  carefulness  on  the  part  of  others,  as 
well  as  exercising  it  yourself,  the  safer  it  will  be  for  all. 

31.  Be  careful  in  doing  your  work  to  avoid  accidents  to  yourself 
and  fellow  workmen. 

32.  Warn  a  man  when  danger  is  near.     He  may  know  all  about  it; 
if  so,  no  harm  is  done.     If  not,  you  may  save  him  from  injury. 

33.  To  be  careless,  thoughtless  or  reckless  means  injury  sooner  or 
later  to  yourself  or  others. 

34.  Employees  are  forbidden  to  take  short  cuts  over  dangerous 

places. 

35.  Every   employee,    whose    duty   requires   him   to   work   with 
appliances  of  any  kind  must  carefully  examine  same  and  report  any 

defects. 

36.  We  will  welcome  suggestions  from  employees  on  anything  of  a 

dangerous  nature. 

37.  Keep  off  railway  or  crane  tracks,  except  the  regular  crossings. 
Before  crossing  any  tracks:  Stop!  Look!  Listen! 

38.  To  avoid  accidents  to  yourself  and  others,  in  case  of  doubt 
take  the  safe  course. 

39.  Always  be  careful  and  take  no  risks. 

40.  The  exercise  of  care  to  prevent  accidents,  is  a  duty  which  you 
owe  to  yourself  and  your  fellow  workmen. 

41.  You  are  responsible  for  the  safety  of  others  as  well  as  of 
yourself. 

42.  Beware   of   blood   poisoning.     A   wire   scratch   will   cause   it 

sometimes. 

43.  It  is  your  personal  duty  to  see  that  all  safeguards  and  signs 
installed  to  promote  safety  are  always  in  good  condition,  and  report 
all  dangers  promptly  to  your  foreman  or  superintendent.  The  pre- 
vention of  accidents  is  one  of  your  most  important  duties. 

44.  Safety  must  be  the  first  consideration  of  all  employees.  In  all 
cases  of  doubt  take  the  safe  course.  When  in  doubt  as  to  the  matter 
of  a  rule,  or  sufficiency  of  a  proposed  precaution,  take  the  matter  up  at 
once  with  your  foreman  or  superintendent. 

45.  Rules  and  regulations  can  be  adopted,  safety  devices  can  be 
attached  to  machines,  guards  can  be  erected  and  warning  signs  posted, 
but  all  are  useless  unless  every  man  is  careful  to  see  that  they  are 
maintained;  unless  every  man  is  careful  to  watch  for  danger;  unless 
every  man  is  careful  to  warn  others  of  danger. 


346  INDUSTRIAL    MEDICINE    AND    SURGERY 

46.  Never  attempt  to  make  a  coupling  or  work  between  cars  on 
the  short  side  of  a  curve. 

47.  It  is  as  much  your  duty  to  comply  with  safety  rules  as  it  is 
your  duty  to  properly  perform  your  work  and  it  is  the  desire  that  you 
be  thoroughly  impressed  with  this  idea. 

48.  Don't  swing  sledge  or  hammer  that  you  know  is  working  loose 
on  handle,  thinking  it  won't  come  off  till  ''next  time. "  You  may  not 
be  hurt  but  what  about  the  other  fellow? 

49.  Don't  expect  your  helper  to  be  as  good  a  mechanic  as  you 
are.  He  isn't  or  he  wouldn't  be  a  helper.  A  little  explanation  as  to 
the  way  the  work  is  to  be  done  may  save  injury  to  one  or  both  of  you. 

50.  At  quitting  time  do  not  hurry  over  railroad  tracks  or  through 
dangerous  places.  Be  on  the  lookout  and  take  sufficient  time  to  be 
sure  there  is  no  danger  ahead.  Serious  accidents  have  been  the  result 
of  not  taking  this  precaution. 

51.  Indifference  to  the  safety  of  others  may  in  the  course  of  events 
sometime  place  your  own  life,  or  that  of  a  member  of  your  family, 
in  danger. 

52.  A  guard  is  placed  on  a  machine  solely  for  your  protection. 
Don't  operate  a  machine  without  a  guard  in  place. 

53.  Stop  machine  before  oiling,  wiping  or  repairing  it,  and  don't 
try  to  operate  a  machine  you  do  not  understand. 

54.  It  takes  less  time  to  explain  why  you  were  late  than  to  make 
out  an  accident  report. 

55.  Be  sure  to  warn  teamsters  and  others  working  in  or  about  cars 
before  coupling  to  moving  cars.  Men  who  are  working  in  cars  often 
want  to  remain  inside  while  cars  are  moving.     Don't  allow  this. 

56.  When  you  find  a  highway  alarm  bell  out  of  order,  ticklers  in  bad 
condition,  or  anything  that  needs  prompt  attention  to  prevent  acci- 
dents, make  a  report  of  it  to  the  proper  person.  You  may  save  some- 
one's life. 

57.  Don't  go  between  moving  cars  or  engine  and  car  for  any 
purpose  whatever.  The  usual  reason  for  going  between  moving  cars 
is  to  turn  the  angle  cock  or  life  pin  when  the  lever  does  not  work. 
Wait  until  cars  stop.  The  few  seconds'  time  required  is  a  good  invest- 
ment. Many  persons  are  injured  and  killed  every  year  by  failure  to 
heed  this  caution. 

58.  Never  try  to  shift  a  moving  belt  by  hand. 

59.  If  you  know  of  some  machine  not  properly  guarded,  don't 
wait  until  someone  gets  hurt  and  say,  "I  told  you  so."  Tell  the 
man  in  charge  of  the  shop  before  an  accident  happens,  and  ask  him 
to  supply  proper  guard. 

60.  Avoid  jumping  upon  moving  cars  or  engines.  Your  work  does 
not  require  it  and  you  cannot  afford  to  take  the  risk. 


THE    SPIRIT    OF    PREVENTION  347 

61.  Never  strike  tempered  steel  with  hammer  or  other  metal  object. 
Many  eyes  are  injured  or  destroyed  from  this  cause  every  year. 

62.  Watch  out  for  trains.     Don't   depend  on  the  other  fellow. 

63.  Keep  frogs,  switches  and  guard  rails  properly  blocked.  This  is 
very  important. 

64.  See  that  material  is  kept  a  safe  distance  from  track,  where  men 
on  side  of  cars  will  not  be  struck  by  it. 

65.  Always  bend  nails  down  before  throwing  boards  away.  Many 
serious  injuries  result  from   stepping  on   protruding  nails. 

66.  Look  in  both  directions  before  stepping  on  any  track,  especially 
in  yards.  Be  particularly  careful  when  crossing  track  near  cars  or 
engines  and  when  about  to  step  from  the  track  containing  same 
upon  another  nearby  track. 

67.  Cultivate  a  habit  of  caution — ^carelessness  often  leads  to  loss 
of  life. 

The  medical  profession  can  claim  great  credit  for  developing  many 
forms  of  prevention.  The  public  health  departments  by  safeguarding 
the  milk  and  water  supply,  by  stimulating  proper  sewage  disposal,  by 
all  forms  of  sanitation  and  quarantine,  have  been  the  means  of  saving 
millions  of  lives  from  disease.  Medical  scientists  have  devoted  their 
time  to  the  study  of  the  causes  of  certain  diseases  and  thereby  made 
possible  the  prevention  of  the  same.  But  our  profession  has  been 
very  lax  in  their  efforts  to  prevent  accidents.  Industrial  accidents, 
claiming  a  greater  toll  of  life  than  many  of  these  diseases,  have  been 
ignored  by  the  majority  of  physicians.  The  great  preventive  surgery 
movement  has  been  left  to  the  laymen  to  develop.  Even  to-day 
our  best  surgeons  receive  injury  cases  into  the  hospital,  operate  and 
otherwise  repair  them  and  finally  discharge  these  patients  without 
giving  one  thought  as  to  means  of  preventing  a  similar  accident  to 
other  men.  ■  - — ^ 

A  surgeon  once  said,  "That  factory  is  a  little  gold  mine  for  me. 
I  get  on  the  average  of  two  fractures  and  six  hand  infections  a  week 
from  among  their  employees." 

When  asked  if  he  had  ever  inspected  the  factory  to  see  why  these 
accidents  were  so  prevalent,  he  replied  that  that  wasn't  his  business. 
This  same  doctor  had  been  the  most  active  advocate  of  cleaning  up  the 
city,  providing  proper  sewage  disposal,  and  otherwise  reducing  the. 
amount  of  typhoid  in  his  home  town.  He  wasn't  mercenary.  His 
vision  of  prevention  had  simply  not  broadened  beyond  the  horizon 
of  disease  prevention.  If  he  had  received  into  the  hospital  six  cases 
of  typhoid  a  week,  he  would  have  moved  heaven  and  earth  to 
discover  the  cause  of  the  epidemic  and  would  have  been  very 
active  in  securing  the  removal  of  the  public  health  officials  responsible 
for  such  a  condition. 


348  INDUSTRIAL    MEDICINE    AND    SURGERY 

It  is  quite  evident  that  our  educational  propaganda  against  acci- 
dents must  extend  to  the  medical  profession.  Municipal  health  depart- 
ments must  develop  a  division  of  safety  as  well  as  one  of  sanitation. 
Health  officials,  municipal  and  state  officers,  and  factory  inspectors  must 
co-operate  to  secure  prevention  of  accidents  in  every  community. 
This  must  become  a  public  fight  against  a  nuisance  that  heretofore 
has  been  tolerated.  For  over  a  year  I  have  fruitlessly  tried  to  have 
''safety,"  as  is  sanitation,  included  as  a  part  of  the  work  of  the  medical 
department   of  the  Army. 

Yet  all  of  the  profession  cannot  be  accused  of  a  lack  of  vision  with 
regard  to  this  form  of  prevention.  Years  before  the  safety  first 
movement,  started  by  laymen,  developed,  a  few  surgeons  connected 
with  industry  began  to  point  out  the  need  of  preventing  accidents 
and  the  need  of  preventing  serious  complications  when  accidents  did 
occur.  When  the  National  Safety  Council  was  organized  these  doctors 
pointed  out  the  need  of  co-operating  with  the  surgeon  in  industry  in 
order  to  secure  the  best  results  This  was  the  basis  of  forming  the 
Health  Service  Section  of  the  National  Safety  Council,  which  deals 
with  accident  prevention  methods  from  the  physician's  standpoint. 

At  about  the  same  time  the  American  Public  Health  Association 
formed  a  section  on  Industrial  Hygiene  which  deals  with  occupational 
disease  prevention  and  many  other  prevention  measures  including 
accident. 

Both  of  these  National  Associations  have  started  movements  for 
disease  and  accident  prevention  which  are  directly  for  the  benefit  of 
the  people  of  the  Nation.  They  have  raised  money  and  are  carrying 
out  many  functions  that  should  be  recognized  by  and  have  the  active 
backing  of  the  National  Government.  In  fact  this  voluntary  machin- 
ery should  be  taken  over  by  the  Government.  Both  should  be  combined 
under  a  Federal  Health  Administration  which  would  make  possible 
the  greatest  advancement  in  accident  and  disease  prevention  through- 
out the  nation.  The  surgeon  in  industry  has  become  the  stanchest 
advocate  of  a  federalized  health  and  safety  department.  The  two 
must  be  combined. 

Just  as  the  doctor  is  finding  it  necessary  to  co-operate  with  and  use 
the  services  of  the  social  worker,  so  he  will  find  it  necessary  to  co-oper- 
ate with  and  use  the  services  of  the  safety  expert.  The  problem 
as  a  whole  involves  the  field  of  preventive  medicine  and  preventive  sur- 
gery and  belongs  therefore  primarily  to  the  medical  profession.  When 
will  they  see  the  light  and  grasp  their  opportunity? 

In  all  the  literature  on  accident  prevention  you  will  find  the 
problem  is  handled  from  the  laymen's  point  of  view  almost  entirely. 
The  outline  of  the  various  values  of  each  procedure,  as  set  forth  by 
Mr.    Young   and   quoted   in  this  chapter,  assigns  the  best  means  of 


THE    SPIRIT    OF    PREVENTION  349 

prevention  to  organization,  education  and  safeguarding.  He  has 
ignored  the  most  effective  agent  for  accident  prevention  in  any 
industry,    namely,   the    surgeon    who    is    on    the    job. 

This  is  not  the  fault  of  Mr.  Young  or  of  other  safety  experts. 
It  is  the  fault  of  the  surgeon  in  industry  who  has  neglected  to 
seize  the  opportunity  of  becoming  the  leader  in  the  accident  prevention 
work.  The  surgeon  in  charge  of  the  human  maintenance  department 
of  an  industry  should  feel  most  keenly  the  stigma  attached  to  every  pre- 
ventable accident  occurring  in  that  industry.  Just  as  he  bends  every 
effort  to  secure  the  best  result  in  reclaiming  an  injured  employee  so 
should  he  strive  to  conserve  the  employees  by  every  preventive 
method. 

It  is  the  duty  of  every  plant  surgeon  therefore  to  make  the  follow- 
ing methods  a  definite  part  of  his  duties: 

1.  Secure  the  active  co-operation  of  the  executives  of  your  concern 
in  accident  prevention,  by  pointing  out  needed  changes,  by  report- 
ing every  accident  and  how  it  could  have  been  prevented,  to  the  chief 
executive,  and  by  enthusiastically  telling  them  of  steps  taken  to  safe- 
guard against  recurrences.  Make  your  reports  and  suggestions  in 
writing,  short  and  to  the  point. 

2.  Instruct  the  employees  individually  and  in  groups  in  safety 
methods.  Use  every  injury  as  a  text  for  instructing  that  employee 
in  prevention  while  furnishing  him  surgical  attention.  Every  pre- 
ventable accident  should  be  posted  on  the  bulletin  boards  through- 
out the  plant,  thus: 

John  Doe,  of  Department  15,  is  in  the  hospital  with  a  skull  frac- 
ture. One  of  his  fellow  employees  carelessly  shoved  a  crate  from  the 
top  of  a  pile  of  boxes  to  the  aisle  below  without  looking  to  see  if  anyone 
was  walking  in  the  aisle.  The  crate  fell  on  John's  head  causing  a  bad 
scalp  wound  and  fracture  of  skull.  Always  look  before  letting  any- 
thing fall  and  avoid  injuring  others. 

Or,  in  case  of  a  minor  accident  that  later  becomes  infected,  post  a 
bulletin  similar  to  the  one  shown  in  the  illustration.  The  picture  of 
the  infected  hand  and  the  warning  to  use  iodin  at  once  and  to  report 
to  the  doctor  at  once  makes  an  indelible  impression  upon  most 
employees  (Fig.  45), 

3.  Make  frequent  inspections  of  the  plant,  first  to  pick  out  possible 
accident  causes,  and  second  to  pick  out  the  employee  who  because  of  his 
general  appearance,  his  methods  of  working,  or  his  mental  attitude, 
might  be  a  potential  cause  for  accidents  to  himself  or  to  his  fellows. 
The  surgeon,  drawing  on  his  experience  of  dealing  with  accidents,  can 
be  invaluable  in  spotting  these  possible  causes. 

4.  Assist  in  the  formation  of  safety  committees,  meet  with  them, 
and  thoroughly  instruct  them  in  every  angle  of  accident  prevention — 


350  INDUSTRIAL   MEDICINE    AND    SURGERY 

especially  call  their  attention  to  the  types  of  employees  who  can  cause 
accidents.  Make  them  inspectors  of  both  the  mechanical  appliances 
and  the  human  machine. 

5.  Secure  a  careful  history  of  every  accident  and  follow  it  up  to  see 
that  the  proper  precautions  are  taken  to  prevent  a  recurrence. 

6.  When  inspecting  an  employee  either  at  work  or  when  he  reports 
to  the  office  for  any  cause  observe  whether  his  clothing  such  as  im- 
proper shoes,  loose  sleeves,  etc.,  might  be  the  potential  cause  of 
accidents. 

7.  Examine  every  injury  case  to  ascertain  if  the  cause  for  the  same 
lies    in  the  physical  or  mental  condition  of  the  employee  himself. 

8.  Use  physical  selection  of  employees  for  work  so  that  the  pre- 
disposed cases  will  not  be  placed  in  hazardous  positions.  This  applies 
to  both  applicants  for  work  and  old  employees. 

9.  Use  every  educational  method  which  will  drive  home  the  les- 
sons of  safety  and  will  cause  each  employee  to  be  alert  to  prevent 
accidents  to  himself  or  others. 

10.  Eat,  sleep  and  breathe  Prevention. 

With  the  growth  of  industrial  medicine  and  surgery  these  pre- 
ventive methods  are  extending  to  all  branches  of  industry  and  to  the 
community  life  of  every  industrial  center.  Preventive  surgery  has 
been  born.  The  fathers  of  this  branch  of  medicine  are  rendering  a 
service  to  humanity  equal  to  that  of  the  leaders  in  preventive  medicine. 
The  field  has  just  been  touched,  however.  Before  us  lies  the  oppor- 
tunity of  spreading  these  principles  to  the  entire  nation. 


CHAPTER  XXIII 

THE   INFLUENCE   OF   NEW  EMPLOYEES  AND   "SPEEDING- 
UP"  ON  ACCIDENT  RATE 

Many  industries  in  this  country  were  forced  to  take  on  great  num- 
bers of  new  employees  and  to  "speed-up"  production  on  account  of 
the  great  demand  made  upon  them  by  war  conditions.  Since  our 
nation  entered  the  world  war  this  ''speeding-up"  process  has  been 
especially  pronounced.  Such  a  condition  invariably  results  in  an 
increase  in  the  number  of  accidents,  no  matter  how  thorough  is  the 
system  of  prevention  which  has  been  developed. 

Under  average  conditions  the  taking  on  of  new  employees  simply 
means  extending  to  them  at  once  every  facility  to  become  acquainted 
with  the  accident  prevention  methods.  They  are  taught  the  use  of 
the  safety  appliances;  instructed  in  preventive  measures  such  as  the 
use  of  tincture  of  iodin,  and  the  reporting  to  the  doctor  at  once  when 
injured;  they  receive  more  personal  attention  from  everybody. 

But  when  there  is  a  universal  speeding-up  of  most  industries  sev- 
eral conditions  conspire  to  frustrate  these  established  methods.  The 
labor  market  is  so  scarce  that  concerns  feel  forced  to  be  more  lax 
in  the  choosing  of  employees.  The  ease  of  securing  work  causes  a 
larger  floating  labor  population.  Men  jump  from  job  to  job  seek- 
ing higher  wages  and  other  inducements.  The  short  time  on  the  job 
tends  to  unfamiliarity  with  the  prevention  rules.  The  medical 
staff  is  unable  to  examine  these  applicants  as  thoroughly  as  formerly, 
and  men  are  assigned  to  jobs  for  which  they  are  physically  unfit. 
The  green  hand  in  an  unfamiliar  occupation  is  always  more  prone  to 
injury. 

Every  surgeon  connected  with  an  industry  has  witnessed  the  great 
increase  in  both  accidents  and  sickness  among  new  employees,  espe- 
cially the  ''floaters,"  when  speeding-up  of  production  has  occurred. 
In  an  industry  where  every  possible  safeguard  was  used,  the  working 
force  was  suddenly  increased  and  every  department  was  speeded-up. 
The  following  statistics  illustrate  the  resulting  accident  disability 
increase: 

351 


352 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Table  8 


Jan.  1  to  Sept.  30 

Oct.  1  to  Dec.  31 

1915 

1916 

Per  cent, 
relative 
increase 

or 
decrease 

1915 

1916 

Per  cent, 
relative 
increase 

or 
decrease 

Average  employees  per  month 

10,649 
4,628 
4.83 

12,485 
5,213 
4.64 

+  17.0 

-  3.6 

-  3.8 

11,937 
2,203 
6.16 

15,238 
2,712 
5.92 

+  27.6 
—   3  6 

Per  cent,  injured 

-   3.9 

Accidents  causing  time  loss 

343 
3,439 

640 
3,411 

+  32.6 
-15.1 

185 
1,622 

411 
2,915 

+  74.2 
+41.8 

Accidents  causing  more  than  seven  days' 

117 

2,784 

123 
2,005 

-10.0 
-38.4 

45 
1,250 

104 
2,279 

+  61.6 

Days  lost  from  above 

+43.0 

409 
566 

469 
450 

-    2.1 
-32.0 

157 
241 

241 
366 

+  20.3 

+  19.2 

It  is  only  after  a  few  years  of  experience  and  after  keeping  careful 
records  for  comparison  that  the  surgeon  in  charge  of  the  Human 
Maintenance  Department  comes  to  realize  that  these  new  employees, 
often  the  transients,  are  the  greatest  factor  in  a  high  accident  rate. 

The  author  once  exhibited  great  pride  in  his  low  infection  rate, 
the  result  of  injuries.  For  weeks  there  had  been  no  hand  infections 
of  any  moment  in  spite  of  the  slight,  practically  non-preventable, 
minor  injuries.  Then  at  the  Christmas  rush  many  new  employees  were 
taken  on.  In  one  week  three  very  serious  hand  infections  developed 
which  caused  great  loss  of  time  and  much  expense.  Two  histories 
will  illustrate  the  point  in  mind. 

Miss  B.,  employed  on  November  30,  stuck  her  palm,  right  hand, 
on  a  spindle.  She  thought  it  was  not  serious  and  so  did  not  mention 
the  fact.  She  knew  nothing  of  the  rules  about  painting  every  injury 
with  iodin  and  reporting  to  the  doctor  at  once.  Two  nights  later  the 
hand  became  very  swollen  and  painful.  Instead  of  calling  the  plant 
surgeon  (she  said  she  didn't  know  that  she  could  call  him).  Miss  B. 
went  to  a  doctor  near  her  house,  who  made  a  slight  incision  in  the 
palm  and  put  on  a  dressing.  Two  days  later  the  nurse  called  when  this 
girl  was  reported  home  on  account  of  sickness.  The  plant  surgeon 
after  three  days  took  charge  of  the  case  and  had  to  deal  with  a  serious 
middle  palmar  abscess  which  caused  eleven  weeks  of  lost  time  from 
work. 

Mr.  C.  was  employed  on  November  27.  Just  before  noon  he 
scratched  his  finger  on  a  nail.  As  the  plant  closed  down  at  noon  be- 
cause of  Thanksgiving  holiday  on  the  twenty-eighth,  Mr.  C.  decided 
not  to  follow  the  foreman's  order  to  report  to  the  doctor.     The  foreman 


THE    INFLUENCE    OF   NEW   EMPLOYEES  353 

who  was  supposed  to  see  that  iodin  was  applied  simply  told  the  man 
to  use  it.  The  next  day  the  finger  was  badly  inflamed.  Instead  of 
calling  at  the  doctor's  office  (open  at  all  times),  Mr.  C.  saw  a  doctor 
who  temporized  with  it.  The  next  day  this  doctor  took  him  to  a 
hospital  and  opened  the  finger.  This  man  failing  to  show  up  after  the 
hohday  and  neglecting  to  report  any  reason,  was  considered  a  "floater. " 
A  week  later,  however,  his  doctor  called  the  plant  surgeon  in  con- 
sultation as  the  infected  finger  had  to  be  amputated.  The  patient 
lost  eight  weeks  time  and  became  a  compensable  case. 

In  both  of  these  examples  it  is  quite  evident  that  the  prevention 
regime  which  should  have  been  in  force  had  fallen  down.  First, 
the  foreman  in  the  case  of  Miss  B.  failed  to  instruct  her  in  the  means  of 
protecting  the  spindle  point  to  prevent  injury.  She  was  not  told 
regarding  the  use  of  iodin  or  reporting  to  the  doctor  at  once. 
Neither  was  she  instructed  as  to  the  means  of  reaching  the  doctor  in 
case  of  injury  or  of  complications  from  same  arising  after  she  reached 
home.  Again  in  the  case  of  Mr.  C.  the  foreman  neglected  to  follow 
instructions  in  regard  to  preventing  infection.  He  also  forgot  about 
this  slight  injury  when  he  dropped  the  man  from  the  pay  roll  without 
investigating  the  cause  of  his  absence.  In  both  cases  the  fact  that 
they  were  new  employees  made  it  possible  for  these  conditions  to 
develop  without  any  special  blame  being  attached  to  anyone. 

These  cases  happened  years  ago.  With  such  experiences  as  a 
teacher,  it  soon  became  evident  that  every  effort  must  be  made  to 
educate  at  once  every  new  employee  in  every  preventive  procedure 
in  operation  in  the  plant. 

The  following  steps  have  been  taken  to  accomplish  this  early 
instruction  of  new  employees  in  accident  prevention  in  this  concern: 

I.  Every  applicant  for  work  must  be  examined  in  the  doctor's 
office.  The  nurse  and  the  doctor  seeing  each  case  must,  as  a  routine, 
tell  him  of  the  purpose  of  the  office  and  especially  instruct  him  that 
in  case  of  an  injury  he  is  to  report  to  the  doctor  at  once. 

II.  The  employment  manager  hands  each  new  employee  a  little 
leaflet  telling  of  the  various  activities  of  the  plant  looking  to  the 
welfare  of  the  employees.  In  this  he  is  told  of  the  purposes  of  the 
doctor's  office  and  his  share  in  the  accident  prevention  methods  in 
vogue. 

III.  In  the  department  and  elsewhere  he  sees  signs  telling  him 
to  use  iodin  at  once  and  report  to  the  doctor  at  once  in  case  of  injury 
no  matter  how  slight  it  may  be. 

IV.  The  foremen  have  standing  orders  to  carefuUy  instruct  every 
new  employee  in  every  form  of  accident  prevention  connected  with 
his  work  in  particular,  and  with  the  plant  in  general. 

Recent  statistics  gathered  from  the  iron  and  steel  trades  by  the 


354  INDUSTRIAL    MEDICINE    AND    SURGERY 

U.  S.   Department  of  Labor  illustrate  this  relation  between  labor 
turnover  and  industrial  accidents  as  follows : 

1.  Accident   frequency  rate  per  one  thousand,   300  work 

days,  of  six  months'  experience  and  under 111.3 

2.  Accident   frequency  rate  per  one  thousand,   300  work 

days,  of  three  to  five  years'  experience 42.4 

It  is  evident  that  every  industry  must  resort  to  more  strenuous 
educational  campaigns  with  new  employees  along  lines  of  disease 
and  accident  prevention  in  order  to  accomplish  greater  results  in  this 
direction.  Constant  appeals  to  the  old  employees  to  help  educate 
the  new  workmen  and  develop  the  spirit  of  prevention  among  them 
is  one  of  the  best  methods  which  can  be  adopted. 


Part  III 
INDUSTRIAL  MEDICINE 


CHAPTER  XXIV 

MEDICAL  EXAMINATION  OF  EMPLOYEES 

The  constant  supervision  of  the  health  of  employees  leads  the 
physician  into  many  and  varied  activities.  He  must  meet  many  of 
the  problems  of  the  pubhc  health  officer,  the  general  practitioner, 
as  well  as  those  of  the  speciaKsts.  But  above  all  else  he  must  be  a 
thorough  diagnostician. 

Early  in  his  work  the  alert  industrial  physician  realizes  that  he  is 
in  the  most  strategic  position  to  diagnose  disease  early  and,  by  insti- 
tuting proper  treatment  at  once,  to  prevent  many  conditions  which 
ordinarily  would  become  serious.  This  is  due  to  the  fact  that  he  sees 
great  numbers  of  cases  at  the  very  beginning  of  their  troubles.  As  a 
rule,  a  man  or  woman  taken  sick  at  work  goes  home,  tries  home  reme- 
dies, and  lies  around  for  a  day  or  two  before  calling  in  the  family  phy- 
sician. This  delay  often  allows  the  disease  to  develop  to  such  an 
extent  that  many  days  are  lost  from  work.  But  when  doctors  in 
whom  the  employees  have  confidence  are  at  hand  they  will  be  con- 
sulted at  once. 

It  behooves  these  doctors  therefore  to  be  constantly  on  the  alert 
to  discover  any  threatened  conditions.  The  prescribing  of  drugs 
without  a  thorough  examination  to  ascertain  their  need,  or  the  care- 
less examination  without  carefully  weighing  every  symptom,  will 
sooner  or  later  result  in  some  preventable  mishap  which  will  cause 
both  suffering  and  financial  loss  to  the  employee  and  will  reflect  seri- 
ously upon  the  ability  of  the  physician. 

Through  centuries  of  scientific  investigations  our  profession  has 
developed  more  and  more  exact  means  of  diagnosing  disease.  Three 
basic  principles  form  the  very  foundation  of  all  diagnostic  effort; 
namely,  the  history,  the  physical  examination,  and  the  various  labora- 
tory examinations.  To  be  thorough  all  of  these  must  be  carefully 
weighed  in  every  case  where  the  least  suspicion  of  disease  exists. 

The  physician  dealing  with  diseased  patients,  or  curative  medi- 

355 


356  INDUSTRIAL    MEDICINE    AND    SURGERY 

cine,  must  utilize  all  of  these  methods  in  practically  every  case.  But 
the  physician  supervising  the  health  of  large  groups  of  people,  dealing 
largely  in  preventive  medicine,  where  he  is  in  a  position  to  study 
the  normal  human  mechanism  in  thousands  of  cases,  must  constantly 
watch  for  suspicious  symptoms  or  signs  and  submit  those  individuals 
to  the  most  thorough  examination. 

This  routine  examination  of  large  groups  of  people  in  order  to 
discover  the  diseased  individuals  among  them  develops  a  different 
type  of  medical  man  from  the  one  who  is  brought  in  constant  contact 
with  the  diseased  patient.  It  is  a  common  observance  among  indus- 
trial physicians  that  the  new  doctor  on  their  staff  discovers  many  more 
cases  of  tuberculosis,  of  heart  disease,  and  of  other  conditions,  when 
making  routine  examinations  of  employees,  than  the  doctor  trained  in 
this  work.  This  is  due  to  the  fact  that  the  average  physician  is  trained 
by  examining  diseased  people  where  findings  are  usually  present  and 
where  these  findings  can  be  interpreted  as  the  cause  of  the  symptoms. 
But  when  a  man  is  examined  who  has  no  symptoms  and  yet  presents  a 
few  adventitious  sounds  in  his  lungs,  or  a  peculiar  heart  tone,  it  is 
difficult  for  this  doctor  not  to  explain  the  same  in  pathological  terms. 

It  is  very  essential  therefore  for  the  industrial  physician  to  develop 
a  keen  sense  of  the  normal  in  the  human  body.  He  must  recognize 
that  certain  changes,  the  result  of  previous  disease,  or  of  certain 
working  conditions,  or  of  numerous  other  causes,  may  occur  in  the 
human  organism  which  will  give  signs  and  even  symptoms  and  yet 
are  not  incompatible  with  a  normal,  healthful  existence  for  that  indi- 
vidual; while  other  signs  of  changes  in  the  body,  even  when  the  man 
complains  of  no  symptoms,  may  be  the  earliest  warning  of  a  pathological 
state.  In  the  latter  case  the  patient  must  be  submitted  to  a  most 
thorough  examination,  the  cause  of  the  sign  discovered,  and  the  proper 
steps  taken  to  abort  a  condition  which  if  neglected  may  result  seriously. 

It  is  utterly  impossible  to  lay  down  hard  and  fast  rules  whereby 
the  beginner  in  industrial  medicine  can  know  v/hen  to  submit  an  em- 
ployee to  a  complete  examination  which  involves  all  laboratory  tests, 
or  when  to  feel  satisfied  with  the  routine  physical  examination  with 
the  ordinary  laboratory  tests.  Neither  can  one  definitely  say  just 
what  physical  handicaps  are  sufficient  cause  for  rejecting  an  applicant 
for  work,  while  others  are  not  of  a  nature  to  interfere  with  employ- 
ment. Nor  will  rules  always  explain  why  a  certain  employee  should  be 
sent  home  for  some  minor  condition  while  another  employee  with  a 
similar  trouble  can  be  allowed  to  remain  on  the  job  knowing  that  his 
resistance  will  overcome  the  condition. 

None  of  these  problems  is  solved  by  rules.  It  is  only  after  years 
of  experience  that  one  becomes  expert  in  weighing  these  matters 
and  solving  them  with  accurate  judgment.     The  best  rule  is  to  always 


MEDICAL   EXAMINATION    OF   EMPLOYEES  357 

give  the  employee  the  benefit  of  the  doubt  and  meet  each  problem  in 
the  safest  manner  for  the  individual  concerned. 

In  a  large  industry  hundreds  of  employees  come  to  the  doctor's 
office  every  day;  and  the  more  reporting  the  greater  is  the  opportunity 
for  health  supervision.  It  is  impossible  to  examine  all  of  these  people 
and  further  it  is  not  necessary.  Certain  ones  come  for  their  routine 
examinations;  others  because  of  accidents,  or  because  of  some  slight 
symptom;  while  others  report  for  various  kinds  of  advice.  The 
medical  staff,  including  the  nurses,  must  be  so  thoroughly  trained 
that  it  is  constantly  on  the  alert  for  that  sign,  symptom  or  even  casual 
remark  on  the  part  of  each  employee  which  indicates  the  need  for  an 
examination  and  study  of  his  case. 

Others  who  are  examined  must  be  put  in  one  of  three  classes: 
normal,  no  findings;  pathological,  definite  findings;  suspicious,  in- 
definite findings.  Those  in  the  first  group  require  no  further  con- 
sideration until  some  condition  arises  which  indicates  another  ex- 
amination. Those  in  the  second  group  must  be  diagnosed  and  placed 
under  observation  and  proper  treatment.  In  the  third  class  fall 
those  cases  which  reveal  findings  which  must  be  studied  before  the 
employee  can  be  definitely  assigned  to  either  the  normal  or  patho- 
logical groups.  The  latter  make  up  the  great  bulk  of  re-examination 
cases.  Many  employeees  are  found  with  some  suspicious  finding 
which  on  re-examination  has  disappeared.  For  example:  The  case 
which  shows  a  sugar  reaction  should  be  examined  at  least  three  times 
before  pronouncing  it  diabetes  as  many  of  these  are  only  transient 
glycosuria. 

If  every  medical  staff  of  an  industry  will  develop  a  keen  sense  of 
detecting  the  employees  needing  examinations,  plus  the  routine 
examination  of  certain  groups,  and  then  will  place  every  employee 
examined  in  one  of  the  above  classes,  it  will  have  estabHshed  a  firm 
foundation  for  an  efficient  system  of  health  supervision. 

The  medical  examination  of  employees  necessitates  engaging  the 
services  of  a  greater  number  of  physicians,  and  enlarging  the  emergency 
doctor's  offices  to  include  examining  rooms  and  laboratory  facilities. 
All  of  this  means  a  greater  expense  to  the  industry.  Therefore,  in 
order  to  expect  industries  to  adopt  such  a  plan  the  industrial  physician 
must  be  able  to  present  a  feasible  system  backed  up  with  the  strongest 
evidence  that  it  is  a  good  business  proposition. 

The  arguments  in  favor  of  an  examination  of  all  employees  of  any 
industry  are  based  upon  the  following  facts: 

1.  That  for  greater  efficiency  an  employer  has  the  right  to  demand 
a  healthful,  physically  and  mentally  normal,  working  force. 

2.  That  an  employee  is  justified  in  demanding  a  healthful,  sanitary 
working  place,  uncontaminated  by  diseased  fellow  employees. 


358  INDUSTRIAL    MEDICINE    AND    SURGERY 

3.  Good  business,  as  well  as  a  humanitarian  spirit,  demands  the 
conservation  of  the  life  and  health  of  employees. 

4.  That  the  medical  staff  of  an  industry  is  employed  to  act  as 
experts  in  accomplishing  the  above  results. 

In  the  past  the  care  of  accidents  has  been  the  chief  duty  of  the 
company  surgeon,  with  very  little  attention  paid  to  the  health  and 
working  ability  of  the  individual  employee.  Likewise,  concerns 
having  company  surgeons  failed  to  realize  the  great  advantage  at 
their  disposal  for  increasing  efficiency  by  utilizing  the  expert  knowledge 
of  these  men. 

Conditions  are  changing.  To-day  we  see  many  of  our  industries 
employing  safety  engineers,  experts  on  ventilation,  visiting  nurses 
to  care  for  the  sick  employees  and  to  better  their  home  conditions, 
and  a  staff  of  physicians  trained  to  diagnose  diseases  in  their  incipiency, 
endowed  with  a  great  enthusiasm  for  results,  and  a  knowledge  sufficient 
to  master  every  detail  that  could  possibly  lower  the  resistance  of  the 
working  force. 

Frequent  inspections  of  employees  and  their  work-rooms,  instruc- 
tions in  hygiene,  sanitation,  and  health  by  personal  talks,  lectures,  and 
printed  articles,  will  increase  the  standards  of  health.  But  the 
systematic  medical  examination  of  employees  is  the  method  par 
excellence  in  this  fight  for  better  health  among  our  working  people. 
By  this  means  the  doctor  comes  in  touch  with  each  employee,  giving 
advice  and  instructions  where  necessary  and  estabhshing  thereby  a 
personal  contact  between  the  medical  staff  and  the  working  force. 
Many  diseases  are  discovered  in  their  incipiency  while  still  curable, 
thus  involving  the  least  expenditure  of  time  or  money  and  therefore 
directly  benefiting  both  the  employee  and  the  employer;  whereas, 
otherwise,  the  employee  would  continue  at  his  work  with  an  inestimable, 
gradual  loss  in  efl&ciency,  until  his  disease  had  become  incurable,  or,at 
best,  could  only  be  controlled.  Again,  by  this  system  of  physical 
examinations  a  great  many  communicable  diseases,  for  example, 
tuberculosis,  are  diagnosed  and  eliminated  from  the  working  force, 
protecting  thereby  healthy  employees  frona  an  imminent  source  of 
infection — their  diseased  fellow  worker. 

Every  employee,  male  and  female,  from  the  head  of  the  concern 
down,  should  be  examined.  Naturally,  the  greatest  interest  should 
center  on  the  present  working  force,  and  here  the  physical  examination 
of  employees  should  begin — there  should  be  a  general  house  cleaning. 
This,  of  course,  will  take  a  great  deal  of  time,  depending  on  the  size 
of  the  working  force  and  number  of  doctors  employed.  The  best 
method  is  the  systematic  examination  of  employees  department 
after  department  until  all  have  been  examined.  But  the  examination 
and  re-examination  of  the  old  working  force  is  inadequate  unless  the 


MEDICAL   EXAMINATION    OF   EMPLOYEES  359 

portals  of  the  industry  are  guarded.  Therefore,  an  examination 
of  all  new  employees  is  the  second  essential  in  raising  the  health 
standards;  likewise,  it  is  the  first  essential  in  protecting  the  concern 
from  workers  who  are  unfit  because  of  disease. 

When  to  examine  these  new  employees  must  be  determined  by  each 
industry.  The  ideal  time  is  before  beginning  work.  From  a  practical 
basis,  however,  this  is  frequently  impossible;  for  instance,  when  a 
large  number  of  people  are  employed,  often  temporarily,  and  upon  very 
short  notice.  Therefore,  a  flexible  rule  must  be  adopted  so  that,  where 
possible,  every  applicant  for  work  shall  be  examined  before  employ- 
ment. Otherwise,  they  shall  be  examined  the  first  week  or  month  of 
their  service. 

Another  ideal  arrangement  in  this  scheme  of  medical  supervision 
would  be  the  repetition  of  these  general  examinations  at  stated  inter- 
vals— say,  every  six  months.  Again,  this  in  not  practicable,  especially 
in  our  larger  industries,  owing  to  the  number  of  doctors  necessary  at 
all  times  to  accompUsh  this.  A  comprehensive  yet  workable  system 
which  the  writer  has  gradually  evolved  during  the  last  ten  years  for 
the  examination  and  re-examination  of  employees  in  a  large  industry 
of  Chicago  having  over  14,000  men  and  women,  is  adaptable  to  any 
concern. 

This  consists  of  a  constant,  careful  watch  for  employees  below  par 
by  the  medical  staff,  nurses,  managers,  floor  bosses,  division  heads, 
and  even  the  employees  themselves. 

Any  employee  who  at  the  first  examination  is  found  to  have  the 
least  suspicious  findings  of  any  disease  is  filed  under  the  heading  of 
"Re-examination."  In  the  course  of  a  week,  month,  or  three  months, 
according  to  the  doctor's  decision,  he  is  recalled  and  again  examined. 
This  is  repeated  as  often  as  his  condition  warrants. 

Other  types  of  suspicious  cases  are  assigned  to  a  nurse  to  have 
temperature  and  pulse  watched  morning  and  evening  for  stated 
periods.  If  any  abnormal  condition  is  found  in  the  temperature  chart 
of  such  an  employee,  he  is  relieved  from  work  until  a  final  diagnosis  is 
made  and  his  future  care  outlined.  Again,  when  an  employee  re- 
turns to  work  after  some  chronic  disease  has  been  cured  or  arrested, 
he  is  frequently  examined  to  guard  against  a  recurrence. 

AU  employees  who  become  sick  while  at  work  are  sent  to  the  doc- 
tor's office  for  a  ''pass"  before  going  home.  And  all  employees  ab- 
sent on  account  of  illness,  of  even  one  day's  dm-ation,  must  secure  a 
permit  from  the  physician  before  returning  to  work.  By  this  rule, 
the  medical  staff  is  enabled  to  watch  those  employees  most  fre- 
quently absent  on  account  of  sickness,  and  thus  quite  often  some 
incipient  disease  is  revealed  as  the  cause  of  this  decreased  working 
capacity. 


360  INDUSTRIAL    MEDICINE    AND    SURGERY 

When  a  concern  has  a  benefit  association  the  examination  of  every 
employee  joining  this  organization  furnishes  another  source  of  secur- 
ing re-examinations. 

The  visiting  nurse  is  one  of  the  best  adjuncts  to  the  doctor's  office. 
While  visiting  a  sick  employee,  she  often  discovers  conditions  at 
home  that  enable  the  physician  to  arrive  at  the  true  nature  of  the 
employee's  trouble  which  might  have  been  overlooked  in  a  routine 
examination. 

Letters  and  personal  talks  by  the  medical  staff,  backed  by  the 
influence  and  instructions  of  the  management  of  a  concern,  will  soon 
arouse  all  sub-managers,  floor  bosses,  and  division  heads  to  take  a 
great  interest  in  the  health  of  workers  under  them.  In  time  they 
learn  to  recognize  the  early  signs  of  disease  and  are  constantly  send- 
ing employees  for  re-examinations. 

This  educational  system  does  not  stop  with  those  in  positions  of 
authority,  but  soon  extends  to  the  employees  in  general,  and  if  their 
confidence  is  once  gained,  these  become  "medical  missionaries,  spread- 
ing the  value  of  the  examination  throughout  the  working  force." 

Periodical  examinations  for  occupational  diseases,  as  prescribed 
by  certain  State  laws,  where  thoroughly  made,  furnish  another 
opportunity  for  supervision  of  health.  Concerns  which  are  forced 
to  employ  men  in  dusty,  dark  places,  or  where  disease  is  more  prone 
to  develop,   should  always  provide  frequent   medical  examinations. 

To  recapitulate:  the  various  channels  through  which  re-examina- 
tion of  employees  can  be  obtained  are: 

Those  found  at  first  examination  to  be  below  par. 

The  repeated  examination  to  guard  against  recurrences. 

Those  becoming  sick  while  at  work. 

Those  returning  to  work  after  an  illness. 

Those  found  by  the  visiting  nurse  needing  examinations. 

Those  referred  by  managers  or  others  in  authority. 

Those  referred  by  fellow  employees. 

Those  examined  for  benefit  association. 

Those  examined  for  occupational  diseases,  or  where  their  work 
indicates  the  necessity. 

The  following  table  shows  the  great  number  of  examinations  of 
employees  which  can  be  made  during  the  course  of  a  year,  and  the 
number  of  re-examinations  made  possible  by  adopting  the  above  sys- 
tem. The  examinations  of  old  employees  were  in  practically  every 
case  re-examinations  as  the  old  working  force  had  been  thoroughly 
"house  cleaned"  six  years  before  at  the  time  the  system  of  examina- 
tions of  all  applicants  for  work  was  adopted.  The  statistics  were 
secured  from  the  records  of  this  same  concern  which,  as  stated,  em- 
ployed approximately  15,000  men  and  women. 


MEDICAL    EXAMINATION    OF    EMPLOYEES  361 

Table  9 

Examinations  and  re-examinations  were  secured  through  the  fol- 
lowing channels: 

Examined  for  employment 17,742 

Old  employees  completely  examined  (including  laboratory  tests). .     7,088 
Old  employees  partially  examined 37,906 

Total 62,736 

Re-examinations 

Found  at  first  examination  to  be  below  par. 4,871 

Examined  to  guard  against  recurrences 4,251 

Reporting  for  pass  home  on  account  of  sickness 8,272 

Reporting  for  pass  back  to  work  after  sickness 18,800 

Referred  by  the  nurses  or  others  of  medical  staff 1,983 

Referred    by  managers,  fellow  employees,  or  reporting  of  own 

accord 4,264 

Examined  for  benefit  association 1,299 

Examined  because  of  occupational  disease  hazards 1,254 

Total 44,994 

The  partial  examinations  referred  to  in  the  above  table  were  those 
where  some  local  condition  was  being  followed  up  and  where  repeated 
thorough  examinations  were  not  necessary  after  they  had  once  been 
made. 

Through  these  same  channels  a  repeated  inspection  of  employees 
can  be  made:  for  instance,  every  complaining  employee  who  comes 
to  the  doctor's  office  should  have  his  temperature,  pulse,  and  weight 
taken.  If  these  are  normal  and  his  history  is  negative  and  his  record 
shows  an  examination  within  the  last  year,  further  examination  will 
not  be  necessary. 

Whenever  an  employee  with  a  contagious  disease  is  found  working 
in  close  contact  with  others,  a  careful  examination  of  every  man  and 
woman  in  this  department  should  be  made,  to  ascertain  if  any  have 
been  contaminated. 

To  make  such  a  system  possible,  every  concern  must  provide  a 
suitable  doctor's  office  at  the  plant.  This  should  consist  of  waiting 
rooms,  history,  examining,  and  consultation  room,  and  a  general 
office,  as  well  as  an  operating  room  (the  care  of  the  injured  must 
always  form  a  large  portion  of  the  company  surgeon's  work),  and  a 
well  equipped  laboratory. 

The  size  of  the  medical  staff  naturally  depends  upon  the  number 
of  employees  and  the  nature  of  their  employment.  For  the  system 
of  medical  examinations  above  outlined,  in  a  concern  employing  5000 
people,  at  least  two  physicians  and  four  nurses  would  be  necessary 
to  accomplish  the  work.  Careful  history  sheets  and  records  with  an 
adequate  tickler  system  should  be  kept  on  every  case. 


362  INDUSTRIAL    MEDICINE    AND    SURGERY 

THE  EXAMINATION 

This  should  consist  of  the  following,  and  is  applicable  to  both 
sexes,  with  only  a  few  exceptions,  which  are  noted. 

1.  History  of  patient  on  regular  blank. 

(a)  Personal  and  family  history. 

(&)  Home  conditions  and  financial  conditions. 

2.  Temperature,    pulse,    height,    and    weight.     (These    can    be 

obtained  by  nurse.) 

3.  General     inspection — color,    nutrition,    any     deformities    or 

co.ngenital  malformations,  gait,  etc. 

4.  Inspection  of  mouth,  teeth,  throat. 

5.  Inspection  of  eyes — Snellen's  test. 

6.  Inspection  and  palpation  of  neck. 

7.  Thorough  examination  of  bare  chest, 
(o)  Lungs. 

(b)  Heart. 

8.  Examination  of  abdomen,  genitalia,  and  extremities  in  men. 
(a)  Hernias. 

(&)  Venereal  disease. 

(c)  Varicosities  or  flat-foot. 

Where  history  of  case  indicates  some  abdominal  or  other 
trouble  in  the  female  employee,  the  services  of  the  doctor 
for  a  further  and  more  thorough  examination,  in  the  presence 
of  the  nurse,  or  the  next  day  when  the  mother  can  come  with 
patient,  are  offered.     If  refused,  send  to  family  physician. 

9.  A    routine    urinalysis    in    all    cases — albumin,    sugar,    and 

microscopic. 

10.  Blood-pressure   and   blood   examinations   in   all   cases  where 

history  and  examination  show  they  are  indicated. 

11.  Other  laboratory  tests  such  as  bacteriological  examinations, 

stomach  analysis,  Wassermanns,  a;-ray  examinations,  etc., 
should  be  provided  when  needed,  either  at  the  plant  office 
or  at  an  outside  hospital. 

12.  Examination   of  the  teeth  of  employees  by  a  dentist   who 

recommends  treatment  when  needed,  is  a  valuable  adjunct. 

13.  Examination  of  eyes  by  a  specialist  is  indicated  in  all  cases 

of  defective  vision  found  at  routine  examination. 

Routine  Procedure  for  examinations 

The  applicants  for  work  and  those  employees  reporting  for  routine 
examinations  can  be  handled  rapidly  and  efficiently  by  the  following 
system. 

1.  Each  patient  enters  with  a  pass  from  the  employment  depart- 
ment   or  from  his  foreman.     A  girl  punches  the  time  of  entrance 


MEDICAL   EXAMINATION    OF    EMPLOYEES  363 

to  the  doctor's  office  on  this  pass.  This  prevents  employees  from 
becoming  lost  and  spending  too  much  time  in  the  office.  It  also 
gives  a  check  to  the  foreman  on  the  length  of  time  spent  in  going  and 
coming  from  the  doctor's  office. 

2.  Sits  in  waiting  room  until  a  record  girl  finds  and  brings  employee's 
history  sheet  to  the  nurse  in  charge.  The  records  are  pulled  in  turn 
from  names  on  the  passes  (2  minutes). 

3.  Enters  one  of  the  history  rooms  where  nurse  takes  history, 
secures  pulse,  temperature,  weight  and  height  record,  makes  eye  test 
(Snellen)  and  records  all  these  on  the  employee's  history  sheet  (5 
minutes). 

4.  Messenger  takes  employee  to  dressing  room  where  he  disrobes, 
urinates  in  specimen  jar  (boy  marks  and  places  in  compartment  basket), 
and  then  goes  into  the  examining  room.  The  physician  stays  here 
constantly,  the  cases  coming  to  him.  By  handling  ten  employees 
at  a  time  the  messenger  boy  is  able  to  keep  ahead  of  the  doctor  and  to 
take  specimens  in  batches  of  ten  to  the  laboratory  where  they  are 
examined  and  recorded  before  the  examination  is  made  (5  minutes). 

5.  Employee  dresses  and  goes  to  dentist  or  other  specialists  for 
special  examination  (10  minutes). 

6.  Passes  out  before  a  nurse  who  inspects  his  record  to  see  that  it  is 
complete  and  to  note  whether  he  has  been  referred  for  some  special 
test  or  examination.     Records  are  collected  by  this  nurse. 

7.  Girl  punches  time  of  leaving  on  his  pass  which  she  has  retained. 
By  such  a  plan  the  employee  that  needs  no  special  conference,  no 

consultation  with  others,  no  treatment  or  advice  can  have  his  ex- 
amination and  record  completed  and  leave  in  22  minutes. 

Other  employees  meanwhile  are  seen  by  the  nurses,  the  surgeons 
in  charge  of  dressings  and  the  chief  of  staff  who  acts  as  a  con- 
sultant, without  interfering  with  these  examinations.  Eight  hundred 
and  seventeen  patients  have  been  seen  and  cared  for  by  eleven  doctors, 
spending  from  three  and  one-half  to  four  hours  each  at  the  office, 
and  assisted  by  twelve  nurses  in  the  morning  and  five  nurses  in  the 
afternoon. 

The  examination  of  girls  is  conducted  in  the  same  way  except  their 
examination  only  includes  head,  neck  and  chest.  Careful  history 
is  obtained  in  each  instance  however  to  ascertain  if  she  should  be 
referred  for  more  thorough  examination. 

The  question  of  the  history  sheets  and  other  records  used  in  these 
examinations  is  dealt  with  in  Chapter  XII. 

Some  Statistics  of  Examinations 

It  is  to  be  deplored  that  physicians  engaged  in  this  work  have  been 
entirely  too  busy  to  keep  careful  statistics.     Managers  of  industry 


364  INDUSTRIAL    MEDICINE    AND    SURGERY 

often  cannot  see  the  value  of  assigning  the  necessary  clerks  to  compile 
statistics.  Valuable  information  is  contained  in  the  records  of  these 
industrial  dispensaries  which  should  be  combed  out  and  contributed 
to  medical  literature. 

Recognizing  the  need  of  some  uniform  method  of  keeping  records 
in  order  to  facilitate  this  compiling  of  statistics,  Dr.  Warren  of  the 
U.  S.  Public  Health  Service  is  working  on  a  record  sheet  which  he 
hopes  to  have  adopted  by  all  physicians  in  industry.  Dr.  Tucker 
of  the  Conference  Board  of  Industrial  Physicians  is  also  preparing  a 
record  card.  It  is  to  be  hoped  that  within  the  next  year  a  simple, 
uniform  system  of  record  keeping  will  be  adopted  by  all  industrial 
dispensaries. 

I  have  collected  the  number  of  diseased  conditions  found  by  medical 
examinations  in  twelve  different  industries,  representing  almost  every 
type  of  work.  The  total  number  of  examinations  made  was  276,420 
during  a  period  of  five  years.  The  relative  incidence  of  diseased 
conditions  found  is  divided  for  purposes  of  comparison  into  the  follow- 
ing groups: 

Group  I.  The  author's  findings  in  112,000  examinations  among 
employees :  engaged  in  clerical  work,  35  per  cent. ;  skilled  light  occupa- 
tions, 20  per  cent.;  heavy  manufacturing  and  laboring  work,  45  per 
cent.  The  proportion  of  female  help  was  about  42  per  cent,  and  of 
male  58  per  cent.     The  average  age  was  twenty-six  years. 

Group  II.  The  findings  of  the  U.  S.  Public  Health  Service  in  936 
steel  workers. 

Group  III.  The  findings  of  the  U.  S.  Pubhc  Health  Service  in  2086 
male  garment  workers. 

Group  IV.  The  average  findings  of  ten  surgeons  in  ten  different 
industries  representing  clerical,  light  manufacturing,  heavy  steel, 
electrical,  rubber  and  other  forms  of  manufacture. 

In  going  over  these  statistics  from  the  various  industries  one  is 
impressed  with  a  number  of  facts: 

1.  The  majority  of  industrial  physicians  are  not  paying  sufficient 
attention  to  foot  conditions  and  deformities  of  the  extremities.  Un- 
doubtedly more  careful  selection  of  work  for  employees  so  handi- 
capped would  improve  efficiency. 

2.  Only  a  very  small  number  of  these  physicians  are  making  care- 
ful tests  of  vision,  otherwise  the  percentage  of  eye  conditions  found 
would  have  been  higher.  In  Group  IV  under  defective  vision  I  have 
reported  the  average  percentage  of  two  concerns  only. 

3.  One  is  impressed  with  the  small  number  of  blind  or  partially 
blind  men  that  are  being  employed  by  these  industries.  Is  this  be- 
cause of  the  compensation  laws? 


MEDICAL    EXAMINATION    OF    EMPLOYEES 


365 


Conditions  found 


Group  I, 
per  cent. 


1.  Tuberculosis,  active. . . 

2.  Tuberculosis,    sus 

pected  or  arrested  .  . 

3.  Other  lung  conditions. 

4.  Organic   heart   disease. 

Functional  heart 

conditions 

Arteriosclerosis 

5.  Nephritis 

6.  Albuminuria 

7.  Rheumatic   conditions 

8.  Hypertrophied   or  dis- 

eased tonsils 

9.  Hernia 

Unprotected  by  truss 
Varicocele,  hydro- 
cele and  undescended 
testicle  

10.  Varicosities 

11.  Flatfeet 

12.  Amputated  members 

13.  Deformities 

14.  Epilepsy 

15.  Defective  vision 

Blind  one  eye 

Blind  both  eyes.  .  .  . 

16.  Deafness 

17.  Skin  diseases 

18.  Defective  teeth 

Anemias 

Diabetes 

Contagious    diseases 
Venereal    diseases 


01.7 

02.10 
03.10 
02.20 

03.00 
03.10 
00.80 
01.70 
05.00 

40.00 
03.20 
02.50 


00.80 
01.00 
04.00 
02.50 


Group  II, 
per  cent. 


Group  III, 
per  cent. 


00'.  04 
35.00 
00.40 

04.00 
04.00 
93.00 
03.10 
00.06 
00.30 
00.60 


00.92 


07.17 
02.90 


00.00 
05.00 
06.60 

26.80 
12.60 


09.63 
32.80 
04.28 
21.90 


00.30 


3.00 

02.00 
10.10 
01.80 


00.50 
02.^0 
00.25 

13.00 
07.50 


03.00 
29.00 
03.00 
00.80 
00.05 


00.66 


Group  IV, 
per  cent. 


01.40 


05.30 
02.25 


00.20 
03.90 
06.20 

03.90 
04.40 


03.20 
05.20 


Average, 
per  cent. 


01 
01 


,30 
,90 


00.02 
33.90 
00.10 
00,01 
02.30 
02.40 
56.90 


01.20 


01.7.55 

01.025 
08.418 
02.288 


00.3.50 
03.225 
04.512 

20.925 
06.925 


04.208 
17.750 
02.740 
06.150 
00 . 028 
17.225 
00 . 365 
00 . 003 
03 . 100 
03 . 200 
37.475 


4.  The  percentage  of  tuberculosis  cases  is  higher  among  the 
garment  workers  of  New  York.  These  figures  were  taken  before  the 
working  conditions  of  this  group  of  employees  were  improved.  I  am 
told  by  different  physicians  famihar  with  this  group  of  employees, 
that  their  tuberculous  incidence  has  decreased  in  the  last  five  years. 

5.  The  circulatory  conditions  among  employees  cause  much  ineffi- 
ciency and  lost  time  unless  these  individuals  are  carefully  supervised 
in  which  case  they  become,  on  selected  duty,  very  efficient.  The 
incidence  of  this  organic  condition  is  in  proportion  to  the  number  of 
rheumatic  conditions  found  among  employees  and  from  the  great 
number  of  diseased  tonsils  and  bad  teeth  found  both  of  these  condi- 
tions can  be  accounted  for. 


366  INDUSTRIAL    MEDICINE    AND    SURGERY 

6.  The  hernia  figures  are  most  interesting.  In  the  industries 
with  the  heaviest  occupations  the  rate  is  usually  highest — one  physi- 
cian in  a  steel  mill  reporting  14  per  cent.  Dr.  Schereschewsky's  fig- 
ures show  a  much  higher  rate  in  the  steel  employees  than  he  found 
in  garment  workers,  or  than  I  found  among  employees  whose  work 
was  of  a  lighter  nature.  This  would  seem  to  bear  out  the  contention 
of  some  that  if  hernia  is  not  a  traumatic  condition  it  can  certainly 
be  classed  as  an  occupational  condition,  being  more  frequent  among 
those  submitted  to  continuous,  arduous  work. 

7.  The  venereal  incidence  is  smaller  than  that  found  in  the  army. 
Employees  with  venereal  disease  do  not  seek  employment  as  a  rule 
where  physical  examinations  are  conducted,  and  they  avoid  paying 
visits  to  the  doctor's  office  for  fear  of  losing  their  job  if  their  disease 
is  discovered.  A  more  generous  policy  toward  these  cases  by  em- 
ployers would  be  of  the  greatest  help  in  discovering  them  and  safe- 
guarding all  concerned. 

No  exhaustive  studies  have  been  made  as  to  whether  all  these 
efforts  in  supervising  the  health  of  employees  have  resulted  in  a  marked 
reduction  in  morbidity  or  mortality.  Many  examples,  however,  can 
be  given  to  prove  that  they  have. 

The  author  found  forty-five  cases  of  tuberculosis  in  1909  working 
in  a  plant.  Five  of  these  died  from  the  disease  because  they  were  dis- 
covered in  an  advanced  stage.  In  1913,  five  years  later,  one  hundred 
and  one  cases  of  this  disease  were  found  with  only  two  deaths  resulting. 
This  reduction  in  the  death  rate  has  been  constant  ever  since  the 
general  house  cleaning  took  place,  eight  and  nine  years  ago. 

In  1915  there  was  an  increase  of  28  per  cent,  in  the  member- 
ship of  the  Benefit  Association  of  this  same  concern,  as  compared 
with  three  years  previously.  In  spite  of  this  increase  there  was 
a  decrease  of  20  per  cent,  in  the  amount  of  sick  benefits.  About 
the  time  we  were  feeling  unusually  happy  over  these  figures  there 
was  an  epidemic  of  so-called  grip  which  soon  destroyed  this  showing. 
It  will  only  be  after  years  of  careful  comparison  that  the  real  benefit 
of  these  efforts  can  be  shown  in  actual  figures. 

During  the  epidemic  referred  to  above  the  death  rate  from  pneu- 
monia greatly  increased  in  this  community.  In  this  concern  how- 
ever out  of  thirteen  hundred  cases  of  "grip"  during  a  period  of  three 
months  there  were  only  three  deaths  from  pneumonia.  The  measures 
taken  to  discover  the  disease  early  and  to  free  the  plant  at  once  of 
the  infected  cases  accounted  for  this  reduction. 

Two  of  the  largest  industrial  insurance  companies  of  the  country, 
the  Prudential  and  the  Metropolitan  have  prepared  an  interesting 
table  showing  the  reduction  in  the  mortality  rate  from  a  few  specific 
causes.     As  all  those  engaged  in  improving  the  health  conditions  of 


MEDICAL   EXAMINATION    OF    EMPLOYEES 


367 


employees  are  responsible  to  some  extent  for  these  results  the  table 
is  herewith  reproduced. 

INDUSTRIAL  MORTALITY  EXPERIENCE 

Reduction  in  Mortality  from  Specific  Causes,  1911  to  1914 


Causes  of  death 


Prudential 


Death  rate 
per  100,000 


'911 


1914 


Per 

cent, 
reduc- 
tion 


Metropolitan 


Death  rate 
per  100,000 


1911 


1914 


Per 

cent, 
reduc- 
tion 


Typhoid  fever 

Measles,    scarlet  fever,  diph- 
theria, whooping  cough .... 

Tuberculosis,  all  forms 

Bronchitis  (acute  and  chronic) 

Pneumonia 

All  external  causes 

Cirrhosis  of  liver 

Total  above  causes 


18.5 

58.9 
201.4 

17.2 
124.1 
102.8 

17.2 


12.5 

47.7 
182.2 

14.0 
110.3 

95.3 

17.1 


540.1 


479.1 


32.4 

19.0 

9.5 

18.6 

11.1 

7.3 

0.6 


11.3 


19.3 

62.7 
195.3 

14.4 
108.4 

95.6 

16.9 


512.6 


13.6 

51.3 
176.1 
11.0 
95.0 
85.9 
13.9 


446.8 


29.5 

18.2 
9.8 
23.6 
12.4 
10.1 
17.8 


12.8 


These  data  are  based  upon  exceptionally  accurate  statements  of  cause  of 
death  and  upon  very  close  approximations  to  the  number  of  the  living  exposed 
to  the  risk  of  death.  The  two  experiences  are  strikingly  similar,  they  both  represent 
large  exposures  of  industrial  workers  and  both  show  a  quite  remarkable  reduction 
in  mortality  from  the  causes  specified,  all  of  which  are  largely  preventable. 


The  examination  of  employees  is  demonstrating  a  great  social  and 
economic  problem  which  sooner  or  later  must  be  faced:  that  is,  what 
is  to  be  done  with  those  diseased  workers  who  are  refused  positions 
in  one  concern  after  another  because  they  cannot  pass  the  physical 
examination?  Some  arrangement  must  be  made  by  the  States, 
by  industrial  insurance,  or  by  the  corporations  themselves,  to  care 
for  these  unfortunate  men  and  women  who  are  found  below  par  and 
not  desirable  as  employees. 

The  problems  which  are  unfolding  because  of  this  new  line  of 
medical  work  in  our  industries  are  many  and  serious.  This  work 
has  surely  demonstrated  the  great  human  wastage  which  has  been 
going  on  since  the  birth  of  our  nation,  and  the  appalling  need  for 
some  means  of  salvaging  the  disabled  employee  whether  his  disability 
is  the  result  of  industrial  conditions,  or  otherwise. 

When  an  industry  adopts  this  system  of  examination,  the  number 
of  employees  found  suffering  from  incipient  disease  will  be  excessive. 
For  in  the  first  year  or  two  the  ratio  of  those  found  diseased  increases 
directly  with  the  number  of  examinations.     After  fom*  or  five  years, 


368 


INDUSTRIAL    MEDICINE    AND    SURGERY 


however,  the  number  of  diseased  employees  in  the  working  force  will 
be  smaller  compared  with  the  number  of  applicants  and  six  month  em- 
ployees found  diseased  (Fig.  52). 

The  attitude  of  the  employee  toward  this  medical  supervision  of 
his  health  is  very  gratifying,  as  a  rule.  He  recognizes  its  great  value 
to  himself  and  his  family.  Very  rarely,  and  usually  only  in  the  very 
ignorant  class,  does  an  applicant  or  an  employee  refuse  to  be  ex- 
amined. If  the  management  is  standing  firmly  behind  the  doctor, 
even  these  few  cases  can  be  persuaded. 

DECREASE  IN  TUBERCULOSIS 

AMONG  THE  OLD  EMPLOYES 


1909 


15.5/        1 5  3"  1 5.5% 


13.3* 


11% 


SJ* 


6.s% 


Q. 
CL 

< 


2.2% 


45  CASES  OF  TUBERCULOSIS 


27.1^ 


Z3M^' 


4.S% 


155  CASES  OF  TUBERCULOSIS 


RESULTS  OF  INCREASED  MEDICAL  EXAMINATIONS  OF  EMPLOYES 
NO  5  YR  EMPLOYES-iaoa-SlO  NO  5  YR  E:MPL0YES-|3H^2Q49 

Fig.  52. — Medical  examinations  caused  a  marked  reduction  in  the  tuberculosis 
rate  among  the  old  employees  even  though  the  number  of  these  was  four  times  as  great 
in  1914  as  in  1909.     This  is  true  of  many  other  chronic  diseases. 

Medical  work  is  growing  rapidly  in  favor  with  employers  as  their 
education  along  these  lines  is  progressing.  Labor  unions  are  also 
in  favor  of  this  work,  providing  it  is  done  from  a  humanitarian  stand- 
point. But  if  done  for  the  purpose  of  picking  only  the  healthiest, 
most  fit  employee  without  any  regard  for  the  welfare  of  those  begin- 
ning to  wear  out  under  the  strain,  then  they  are  opposed  to  it. 

Five  years  ago  it  was  my  experience  to  find  family  physicians 
opposed  to  all  industrial  medical  systems.  A  diagnosis  of  incipient 
tuberculosis,  for  instance,  was  often  the  cause  of  a  severe  arraign- 
ment from  the  family  physician  and  the  enmity  of  the  employee  and 


MEDICAL   EXAMINATION    OF    EMPLOYEES  369 

his  family.  If,  however,  the  company  physician  has  thoroughly 
diagnosed  his  case  by  repeated  examinations  and  careful  laboratory 
study,  he  is  in  a  position  to  stand  his  ground,  and  the  subsequent 
course  usually  justifies  his  position.  In  time  the  family  physician 
comes  to  recognize  the  great  value  of  this  careful  supervision  of  his 
patients  while  they  are  at  work,  especially  if  the  employee  is  referred 
to  him  for  treatment,  independently  or  in  co-operation  with  the  com- 
pany physician, 

24 


CHAPTER  XXV 
MEDICAL  EXAMINATION  OF  APPLICANTS  FOR  WORK 

In  the  various  armies  of  the  world  one  of  the  functions  of  the  medi- 
cal officers  has  always  been  the  physical  examination  of  new  recruits. 
This  was  done  for  the  purpose  of  picking  only  the  physical  fit  as  it 
was  felt  that  only  such  men  could  stand  the  hardships  of  a  soldier's 
life. 

But  the  economic  demand  for  man-power  in  all  the  countries 
engaged  in  this  world  war  has  forced  them  to  adopt  a  plan  of  physical 
selection  for  work  of  those  men  not  quite  fit  for  general  military  duty. 
In  our  own  country  after  the  course  of  a  year  we  are  utilizing  this 
class  of  men.  Soldiers  unfit  for  general  military  duty  are  being  as- 
signed to  development  battalions  where  they  are  given  training  ac- 
cording to  their  physical  ability  to  stand  it,  and  then  are  carefully 
classified,  by  qualified  medical  officers,  and  assigned  to  selected  duties 
where  they  can  be  efficient  in  spite  of  their  physical  handicaps.  Draft- 
ees with  physical  handicaps  are  also  being  sent  to  camps  for  Hmited 
duty  men  and,  after  their  physical  classification,  are  assigned  to 
properly  selected  occupations.  Tens  of  thousands  of  able-bodied 
soldiers  will  thus  be  freed  from  lighter  duties  for  the  heavy  combat 
service. 

This  radical  change  in  the  practices  of  the  army,  which  has  enabled 
them  to  utilize  man-power  to  a  greater  extent  than  ever  before,  will 
have  a  far  reaching  influence  in  the  employment  practices  of  our 
industries.  Henceforth  the  new  recruit  in  the  industrial  army  will 
be  classified  physically,  as  well  as  technically,  and  assigned  to  work 
by  considering  both  qualifications  if  industry  desires  the  most  effi- 
cient   system. 

Long  before  the  war  a  few  of  our  industries  had  begun  a  thorough, 
systematic  physical  examination  of  applicants  for  work.  In  fact,  the 
experiences  of  some  of  these  industries,  where  this  procedure  had  proven 
both  practicable  and  profitable  were  influential  in  establishing  these 
new  standards  in  the  army. 

There  are  isolated  examples  of  the  examination  of  appHcants 
for  work  prior  to  1912  but  it  was  about  this  date  that  the  practice 
was  introduced  to  any  extent  in  industry.  It  is  often  stated  that  ex- 
amination of  applicants  and  of  employees  did  not  start  until  after 
certain  states  had  enacted  employees  compensation  acts.     True  the 

370 


MEDICAL   EXAMINATION    OF    APPLICANTS    FOR    WORK         371 

enactment  of  these  laws  gave  a  marked  stimulus  to  the  method  be- 
cause many  concerns  felt  that  it  was  necessary  to  rule  out  the 
defectives  in  order  to  protect  themselves  from  liabilities.  The  chief 
surgeon  of  one  of  the  largest  industries  in  the  country  expressed  it 
thus: 

'•No  such  examinations  were  conducted  by  us  prior  to  the  com- 
pensation act.  It  was  thought  best  to  let  every  man  apply  for  a  job, 
try  himseK  out,  if  he  could  stand  up  under  the  work  and  wished  the 
job,  it  was  his.  At  the  present  time  physical  examinations  are  being 
conducted  so  as  to  fit  defective  men  into  such  posts  in  our  industry 
as  will  interfere  least  with  existing  defects.  The  physical  examina- 
tions also  disqualify  many  men  seeking  employment.  The  compen- 
sation Hability  is  too  great.  The  industries  do  not  like  to  discriminate 
against  men  seeking  employment,  as  their  services  are  much  needed. 
A  man  with  one  eye  is  often  a  good  man  for  his  post  yet  such  a  defect 
at  present  disqualifies.  'Everybody  is  doing  it,'  and  it  was  not  until 
we  were  convinced  that  we  were  getting  only  the  refuse  of  the  rail- 
roads and  steel  mills,  men  who  could  not  qualify  in  competitive  phys- 
ical examinations,  that  our  company  began  such  physical  examina- 
tions in  May,  1916." 

But  those  concerns  which  really  initiated  medical  examinations  did 
so  before  any  such  laws  were  enacted,  and  the  basis  for  so  doing  was 
not  selfish,  but  solely  for  the  protection  of  their  working  forces.  Few 
of  us  in  the  beginning  realized  all  the  ramifications  this  procedure 
would  have  in  the  economic  and  social  existence  of  our  country. 
Some  of  these  ramifications  have  been  for  good  and  some  for  evil  but 
an  equitable  adjustment  for  all  concerned  is  gradually  taking  place. 
And  it  is  an  efficiency  measure  which  both  employers  and  labor 
unions  now  recognize  as  here  to  stay. 

In  Chapter  XXI  I  have  referred  to  the  old  system  of  throwing  men 
into  jobs  without  knowing  their  fitness  for  the  same  and  the  human 
waste  and  financial  loss  to  employers  which  such  a  system  involved. 
This  hit  or  miss  method  of  employment  is  still  in  vogue  in  the  majority 
of  industries.  It  is  one  of  the  chief  factors  in  the  high  percentage  of 
labor  turn-over.  Inefficiency  on  the  job,  needless  premature  break- 
downs the  result  of  overwork,  unnecessary  accidents,  misunder- 
standings between  boss  and  workman,  and  the  discontent  of  labor 
can  more  often  be  traced  to  poor  health  conditions  than  to  any  other 
one  cause.  The  physical  selection  of  men  for  proper  work  combined 
with  proper  health  supervision  is  the  cure  for  many  of  these  difficulties. 

WHEN  TO  EXAMINE 

The  only  proper  time  to  examine  an  applicant  for  work  is  before 
he  is  employed.     No  working  force  is  sufficiently  protected  from  con- 


372  INDUSTRIAL   MEDICINE    AND    SURGERY 

tagious  diseases  in  applicants  if  these  are  allowed  to  work  for  a 
number  of  days  before  being  examined.  The  defective  new  employee 
may  cause  an  accident  to  himself  or  others  during  those  early  days  of 
work  before  he  is  examined.  The  loss  in  inefficient  labor,  in  breaking 
an  employee  in  to  a  job  and  then  losing  him,  and  the  uncertainty  on 
the  part  of  the  the  employee  as  to  whether  he  will  be  retained  or  not, 
all  point  to  the  importance  of  making  this  examination  before  he 
goes  to  work.  Above  all  it  is  a  gross  injustice  to  employ  a  man 
and  then  a  month  later,  because  he  has  some  physical  defect  which 
is  found  at  the  examination  supposed  to  be  given  to  applicants,  dis- 
charge him  because  of  physical  disability.  Rightfully  he  asks  if  he 
hasn't  been  doing  his  work  efficiently  in  spite  of  that  handicap. 

An  exception  to  this  rule  may  be  made  in  the  case  of  employing 
a  large  number  of  men  at  one  time  for  temporary  work  as  before  the 
Christmas  rush.  But  that  concern  is  the  wisest,  and  after  all  the 
most  frugal,  which  employs  more  doctors  at  such  a  time  and  main- 
tains its  standards. 

This  true  example  can  be  given  illustrating  the  bad  effects  of  post- 
poning this  examination  of  applicants. 

J.  B.  was  employed  by  an  electrical  concern  as  a  mechanic.  Phys- 
ical examinations  of  applicants  were  required  by  this  industry  but  the 
doctors  were  three  months  behind  in  their  work.  Finally  J.  B., 
after  3  months  of  efficient  work  as  a  mechanic,  was  examined  and 
it  was  discovered  that  he  was  blind  in  his  left  eye.  This  did  not 
interfere  in  his  work  but  it  added  to  his  liability  to  the  concern  in 
case  of  an  injury  to  his  good  eye.  Therefore  he  was  dismissed. 
The  doctor  who  handled  this  case  was  ashamed  of  it  and  framed  up 
an  excuse  with  the  man's  foreman  in  order  to  fire  him.  If  this  was 
sufficient  reason  for  not  accepting  the  man  for  work  then  he  should 
have  been  examined  and  refused  employment  when  he  applied. 
As  it  was  a  great  injustice  was  done  the  man  and  his  future  was 
jeopardized. 

REASONS  FOR  EXAMINATION 

The  industries  adopting  this  system  did  so  for  one  of  the  following 
reasons.  You  will  note  that  some  of  them  are  altruistic,  good  busi- 
ness reasons,   while  others  have  a  selfish  basis  only. 

1.  To  maintain  the  standards  of  health  among  the  old  employees. 

2.  To  enable  the  selection  of  work  according  to  the  physical  quali- 
fications of  the  applicant. 

3.  To  pick  only  the  physically  fit. 

4.  To  protect  the  concern  from  employees  who  might  add  to  their 
accident  liability,  thus  increasing  the  insurance  premium. 


MEDICAL   EXAMINATION    OF    APPLICANTS    FOR    WORK        373 

5.  To  keep  out  the  labor  agitator  and  other  undesirable  employees 
(claimed  by  opponents  to  the  plan). 

In  most  concerns  where  examinations  of  applicants  are  conducted 
the  old  employees  have  been  thoroughly  examined,  industrial  hygiene 
methods  are  in  vogue,  and  all  forms  of  health  supervision  established. 
It  is  only  logical  therefore  that  as  far  as  possible  they  desire  to 
maintain  these  standards  of  health.  The  more  comprehensive  their 
standards  are  however  the  more  broad-minded,  as  a  rule,  are  they 
toward  employing  handicapped  individuals. 

Applicants  with  contagious  conditions  are  not  employed  because 
of  their  danger  to  fellow  employees.  During  the  course  of  one  year 
in  an  industry  conducting  physical  examination  the  following  conta- 
gious diseases  were  found  by  the  author  and  his  associates  among 
8000  appHcants  and  were  a  cause  for  rejection: 


Tuberculosis 102 

Syphilis  (active) 10 

Gonorrhea 16 

Diphtheria 8 

Scarlet  fever ,. ,  2 

Measles 6 

Mumps 6 

Streptococcic  sore  throat 18 

Small-pox r.  .  1 

Traucoma 1 

Total 170 

It  is  self-evident  that  the  health  of  employees  in  this  industry  was 
greatly  protected  by  preventing  these  applicants  from  going  to  work. 
The  financial  saving  to  the  concern  by  preventing  at  least  five  pos- 
sible epidemics  among  their  working  force  cannot  be  estimated. 

In  spite  of  new  theories  in  regard  to  the  absence  of  danger  from 
mingling  with  tuberculous  patients  I  contend  that  it  is  a  much 
safer  business  policy  to  protect  the  employees  from  intimate  contact 
with  this  disease  in  their  working  rooms. 

Other  appUcants  are  rejected  because  they  have  some  diseased 
condition  that  makes  work  of  any  kind  dangerous  for  them.  No 
health  standard  can  be  maintained  if  a  man  with  a  broken  compen- 
sated heart,  or  a  girl  with  an  advanced  exophthalmic  goitre  is  allowed 
to  go  to  work.  The  occupation,  no  matter  how  carefully  selected  may 
be  detrimental  to  their  health  and  cause  much  lost  time  from  work 
on  the  one  hand  and  great  physical  damage  to  them  on  the  other. 
This  does  not  mean,  however,  that  all  organic  diseases  are  causes  for 
rejection. 


374  INDUSTRIAL   MEDICINE    AND    SURGERY 

The  second  reason  for  examining  applicants,  namely,  to  enable 
the  selection  of  work  according  to  their  physical  quaHfications,  is  one 
of  the  most  logical  business  reasons  which  can  be  advanced  for  this 
procedure.  Every  efficiency  engineer  recognizes  the  value  of  placing 
"round  pegs,  in  round  holes."  No  method  of  picking  these  pegs  is 
complete  that  does  not  include  a  physical  examination. 

Examples  have  already  been  given  illustrating  the  human  danger 
and  the  financial  loss  that  can  follow  the  usual  system  of  throwing 
men  into  jobs  without  any  thought  given  to  their  physical  qualifica- 
tions. The  example  of  the  man  who  was  employed  as  a  crane  operator 
and  whose  crane  was  responsible  for  the  death  of  one  man  and  the 
injury  of  another  is  one  of  the  best  illustrations  we  can  use.  These 
accidents  were  attributed  to  other  causes  but  when  the  crane  operator 
was  finally  examined  he  was  found  to  have  an  eye  condition  which 
destroyed  part  of  his  vision,  especially  his  perspective. 

The  mental  qualifications  of  a  man  for  types  of  work  must  also  be 
considered  in  this  selection  of  the  round  hole  for  the  round  peg.  The 
employment  manager  usually  becomes  a  practical  psychologist  and 
is  able  to  select  these  jobs  properly.  But  the  physician  can  often 
detect  mental  conditions  not  apparent  to  the  employment  man. 
For  this  purpose  he  should  talk  with  every  employee  and  applicant, 
asking  questions  and  observing  his  manner  of  responding  to  certain 
requests  in  order  to  determine  the  mental  attributes  of  each.  When 
deemed  advisable  the  suspicious  cases  should  be  referred  to  a  practical 
psychiatrist  for  a  decision  as  to  their  mental  fitness  for  work.  Every 
industrial  physician  can  develop  this  ability  of  diagnosing  mental 
troubles  even  though  he  cannot  subdivide  the  conditions  into  the  many 
types  of  nervous  and  mental  diseases. 

Even  after  an  applicant  has  been  examined  and  accepted  these 
mental  cases  will  be  cropping  out.  The  majority  of  them  are  only 
functional  or  temperamental.  Often  incompatible  work  will  bring 
the  temperamental  condition  to  the  foreground. 

One  employee  was  recommended  for  discharge  on  account  of 
inefficiency  by  his  foreman.  Before  this  was  done  the  employment 
manager  sent  him  to  the  doctor  for  another  examination.  The 
man  was  sullen,  morose  and  above  all  disheartened.  He  had  been 
working  as  a  packer  during  the  day  and  studying  as  a  violinist  in  the 
evenings.  The  fellow  employees  were  rude  to  him  and  he  could 
not  understand  their  ways.  Physically  he  was  perfect.  Mentally 
he  was  temperamental.  A  conference  between  the  doctor  and  employ- 
ment manager  resulted  in  the  man  being  transferred  to  the  position 
of  assistant  foreman  over  a  department  of  girl  typists.  He  was 
told  to  fix  up  their  working  room,  make  it  home-like,  give  the  girls  a 
little   recreation  for  ten  minutes  in  the  morning  and  afternoon.     In 


MEDICAL   EXAMINATION    OF   APPLICANTS    FOR   WORK        375 

six  months  he  had  a  glee  club  developed  among  these  employees  and 
other  activities  started  which  made  the  girls  enthusiastic  about  their 
department  and  most  loyal  to  their  foreman  and  the  concern.  The 
output  of  work  increased  over  50  per  cent.  This  man  is  now  manager 
of  a  department  and  is  happy  in  his  work.  Often  the  nervous  energy 
behind  a  temperamental  employee  can  be  used  as  a  great  dynamic 
force  if  directed  in  the  right  channels. 

Those  concerns  which  adopt  this  system  of  examination  for  the  pur- 
pose of  picking  only  the  physically  fit  employees  may  be  playing  a  long 
stroke  of  business  but  they  are  not  assuming  their  share  of  responsi- 
bihty  toward  society.  The  handicapped  employee  is  ever  in  our 
midst.  While  he  has  his  brain  power  left  he  is  able  to  be  efficient  in 
some  selected  capacity.  Unless  this  opportunity  is  given  him  he 
becomes  a  non-productive  agent  and  a  drain  on  society.  Every 
concern  is  benefited  by  all  things  which  improve  the  social  and 
economic  conditions  of  their  community.  Refusal  to  assume  their 
share  of  this  burden  reacts  on  them  as  well  as  on  the  other  industries. 

From  a  recent  questionaire  sent  out  in  regard  to  the  employment  of 
handicapped  men  the  writer  discovered  that  many  concerns,  even 
where  physical  examinations  of  applicants  were  conducted,  were 
employing  such  men.  Those  with  diseased  conditions  unfitting  them 
for  their  work  were  rejected,  but  the  disabled  men,  the  armless,  the 
legless,  the  bhnd  in  one  eye,  were  being  employed.  This  may  be  due 
to  the  fact  that  man-power  is  at  such  a  premium  now,  but  the  testi- 
mony of  most  of  these  concerns  would  indicate  that,  where  jobs 
are  properly  selected,  these  handicapped  individuals  make  better 
employees  than  the  able-bodied,  and  that  as  far  as  they  are  concerned 
these  are  permanent  employees. 

One  concern  reported  that  it  employed  all  legless  and  one  armed 
men  who  appHed  and  that  it  had  carried  out  this  pohcy  for  five  years. 
To-day  forty  such  men  work  here.  Five  of  these  have  advanced  to 
the  position  of  foreman,  one  to  a  manager.  Their  reasons  for  favoring 
this  type  of  a  man  were  purely  business  reasons  and  can  be  stated  as 
follows : 

1.  Lessens  labor  turn-over.  These  men  hesitate  to  change  jobs 
more  than  do  the  ablebodied. 

2.  Make  more  loyal  employees.  They  appreciate  the  opportmiity 
given  them  to  work  in  a  world  that  has  heretofore  tried  to  place 
them  in  the  scrap  heap. 

3.  Lessens    troubles    from   labor   agitators — because   of   loyalty. 

4.  Have  a  greater  output.  They  stick  closer  to  the  job,  do  not 
move  about  the  plant  as  much  as  one  with  two  legs.j 

5.  Are  more  punctual  and  have  less  absenteeism.     As  a  rule  they 


376.  INDUSTRIAL    MEDICINE    AND    SURGERY 

take  a  more  serious  view  of  life,  do  not  use  alcohol,  stay  home  of  nights, 
and  avoid  exposures  that  lead  to  sickness. 

6.  Take  a  pride  in  their  accomplishments.  The  reaction  from 
those  days  when  they  thought  they  were  cripples  makes  them  strive 
the  harder  to  make  good.  As  one  of  them  said:  "It  takes  a  lot  of 
extra  effort  at  first  to  overcome  your  handicap  and  then  when  it  is 
overcome  this  extra  effort  ought  to  push  you  away  ahead  of  the  other 
fellow." 

One  employer  was  quite  proud  of  the  fact  that  he  had  a  number  of 
"cripples"  working  for  him.  His  chief  argument  in  favor  of  employ- 
ing such  men  was  "they  worked  a  lot  cheaper  than  the  other  fellows." 
His  plant  was  visited  and  the  lack  of  incentive  for  these  employees 
which  was  witnessed  there  accounted  for  them  still  being  "cripples." 
The  handicapped  man  who  has  overcome  his  condition  and  made  good 
is  never  a  "cripple." 

So,  the  concern  which  is  picking  only  the  physically  fit  employees 
may  not  possess  such  a  strong  business  sagacity  after  all.  Usually 
such  a  one  is  selfish  in  other  matters  and  sooner  or  later  this  selfishness 
will  be  their  undoing.  The  lack  of  loyalty  on  the  part  of  employees 
who  cannot  respect  their  employer  is  an  ever  present,  incalculable  loss 
to  any  industry. 

With  the  enactment  of  employees'  compensation  laws  a  great 
stimulus  was  given  to  examinations  of  applicants.  Many  concerns 
adopted  this  measure  as  a  means  of  protection  against  the  employee 
who  might  increase  his  accident  rate.  Practically  all  the  state  compen- 
sation laws  hold  the  employer  responsible  for  total  disability  when 
subsequent  injury  to  an  already  handicapped  individual  renders  him 
totally  disabled.  For  instance  if  a  one  eyed  man  is  employed  and 
by  accident  he  loses  the  other  eye  the  concern  must  pay  compensation 
for  the  loss  of  both  eyes,  that  is,  total  blindness. 

The  tendency  of  all  industrial  boards  to  call  most  hernias  traumatic, 
and  therefore  compensable,  placed  a  ban  on  the  employment  of  men 
with  hernias. 

Insurance  companies  began  to  raise  the  premium  rate  for  concerns 
employing  men  who  were  potential  accident  liabilities.  This  added 
greatly  to  the  discrimination  against  handicapped  individuals  and 
forced  many  to  employ  doctors  to  make  physical  examinations  of 
applicants  from  this  standpoint  of  protection  alone. 

No  other  one  thing  has  caused  greater  criticism  of  physical  examina- 
tions of  employees  than  this  attitude  on  the  part  of  employers 
and  insurance  companies.  Few  could  see  that  neither  physical 
examinations,  nor  the  doctors,  were  to  blame,  but  rather  the  compen- 
sation laws  which  placed  this  injustice  on  the  employer  and  the 
handicapped  applicant  for  work. 


MEDICAL   EXAMINATION    OF   APPLICANTS    FOR   WORK        377 

During  the  last  year  the  government's  plans  for  the  reconstruction, 
re-education  and  re-employment  of  the  returned  disabled  soldier  has 
injected  a  new  issue,  a  new  viewpoint  into  the  question  of  employees' 
compensation.  All  agree  that  these  disabled  soldiers  must  be  employed 
by  industry.  All  agree  also  that  the  employer  should  not  be  held 
responsible  for  the  increased  liability  due  to  the  handicapped  condition 
of  these  men.  Therefore  committees,  congressmen  and  state  senators 
are  considering  means  of  so  modifying  all  compensation  acts  that 
this  injustice  will  be  eliminated.  When  it  is  so  modified  it  must 
include  the  disabled  of  industry  as  well  in  its  interpretation.  Thus 
will  the  last  excuse  for  using  physical  examinations  of  applicants  as 
a  means  of  discriminating  against  the  disabled  man  be  cast  aside. 

Many  union  labor  leaders  at  first  bitterly  opposed  the  examina- 
tion of  employees.  They  contended  that  it  was  only  a  means  of 
discrimination  against  the  labor  union  men;  of  keeping  men  who  were 
radical  in  their  views  out  of  the  working  force  by  claiming  that  the 
doctor  had  found  them  physically  unfit. 

I  doubt  if  any  industry  has  ever  used  this  as  an  excuse  to  so  dis- 
criminate. But  there  is  evidence  that  the  doctor  has  been  asked 
to  use  sickness  as  an  excuse  to  get  rid  of  some  undesirable  employee. 
Often  it  is  hard  to  fire  a  man  and  the  doctor's  office  will  offer  an  easy 
solution  to  this  difficulty  if  the  the  doctor  will  only  follow  directions. 
Knowing  this  to  be  a  fact  we  can  conceive  of  these  fears,  of  the  labor 
union  men,  as  having  some  foundation. 

It  is  imperative  that  the  medical  staff  of  an  industry  be  absolutely 
square  at  all  times  with  both  the  employee  and  the  employer.  He  can- 
not favor  one  against  the  other.  His  decisions  must  be  made  altogether 
upon  the  evidence  of  the  case.  Subterfuges  which  could  reflect  upon 
his  professional  honesty  will  soon  rob  him  of  the  respect  and  confidence 
of  all. 

REJECTION  STANDARDS 

It  has  often  been  suggested  that  a  list  of  diseases  and  the  subnormal 
conditions  for  which  men  should  be  rejected  should  be  prepared  by  a 
representative  group  of  industrial  surgeons.  The  standards  for  re- 
jection in  the  army  have  been  offered  as  a  basis.  Such  a  plan  would 
work  great  injustices  on  thousands  of  individuals.  The  variations  in 
occupations,  hours  of  labor,  plant  conditions,  attitude  of  employers 
toward  employees  and  many  other  things  on  the  one  hand,  and  the 
variations  in  the  seriousness  of  specific  conditions  in  different  individ- 
uals and  the  interpretations  of  the  different  conditions  by  the  medical 
men  on  the  other  hand,  make  such  a  standardization  of  specific  causes 
for  rejections  impossible. 

The  case  of  each  individual  must  be  considered  separately,  and  the 


378  INDUSTRIAL    MEDICINE    AND    SURGERY 

decision  as  to  his  fitness  for  work  must  depend  upon  his  individual 
physical  and  mental  quahfications  and  the  nature  of  occupations 
available  in  the  given  industry. 

The  Ford  Motor  Company  claims  to  have  the  policy  of  "No  Rejec- 
tions for  Work."  Every  applicant  is  given  a  thorough  examination, 
his  physical  defects  noted,  and  then  he  is  assigned  work  where  he  can 
be  efficient  in  spite  of  his  handicap.  Naturally  contagious  cases  would 
not  be  accepted  at  once.  This  careful  fitting  of  the  job  to  the  man 
has  resulted  in  the  greatest  efficiency  in  this  plant.  Even  men  who 
are  bHnd  have  been  found  useful  and  more  efficient  than  others  especially 
on  the  finer  electrical  work,  as  winding  of  armatures.  There  is  no 
attitude  of  charity  in  this  policy  but  it  is  placed  on  a  straight 
business  basis. 

For  a  large  concern  where  many  kinds  of  occupations  are  represented 
this  policy  is  logical.  But  a  smaller  industry  perhaps  could  not  find 
employment  for  every  type  of  handicapped  individual  without 
introducing  the  element  of  charity. 

Representing  the  other  extreme  are  a  few  concerns  which  have 
definite  standards  for  rejection.  These  reject:  all  cases  of  blindness, 
one  eye  or  both;  deafness  in  both  ears;  badly  infected  teeth;  cases 
of  tuberculosis  or  suspicious  lung  findings;  organic  heart  disease; 
nephritis;  diabetes;  all  cases  of  hernia;  varicose  veins;  marked  deform- 
ities of  extremities;  epilepsy;  any  degenerative  nervous  conditions; 
syphilis  or  gonorrhea.  These  conditions  raise  their  rejection  Ust  to 
approximately  15  per  cent,  of  all  applicants.  They  accept  many 
employees  with  minor  handicaps  and  therefore  cannot  be  placed  in 
the  class  of  those  concerns  picking  only  the  most  fit  material.  The 
latter  concerns  reject  from  18  to  20  per  cent,  of  all  appHcants 

In  between  these  two  extremes  of  accepting  all  comers  and  of 
rejecting  all  with  specific  conditions,  we  find  a  large  group  of 
industries  that  have  adopted  the  plan  of  individual  selection  for 
proper  work. 

No  definite  standard  of  causes  for  rejection  can  be  outhned  for 
these  concerns  but  their  policy  can  be  stated  in  general  as  follows: 

1.  All  contagious  cases  must  be  rejected — later  they  may  return 
for    examination. 

2.  Cases  of  total  bHndness  are  not  accepted  as  a  rule.  A  job 
may  be  found  for  some  specific  case.  One  eye  blindness  is  accepted 
but  assigned  to  work  where  the  hazard  to  the  good  eye  is  reduced 
to  a  minimum, 

3.  Locomotor  ataxia,  paresis  and  general  nervous  conditions  are 
not  accepted  as  a  rule,  although  the  milder  forms  may  be  placed  at 
selected  work. 

4.  Epileptics  are  not  accepted  by  the  majority.     A  few  concerns 


MEDICAL    EXAMINATION    OF    APPLICANTS    FOR    WORK        379 

find  suitable  work  for  these  individuals  where  the  danger  of  injury 
resulting  during  an  attack  is  obviated  as  far  as  possible. 

5.  Tuberculous  cases  are  rejected.  Some  of  the  concerns  assume 
the  duty  of  seeing  that  these  rejects  are  placed  under  proper  treat- 
ment by  the  city,  county  or  with  their  family  physician. 

6.  Other  lung  conditions  are  decided  on  their  merits.  An  asth- 
matic may  be  rejected  because  the  only  work  available  for  him  is  in 
a  very  dusty  occupation.  Careful  selection  of  proper  work  is  neces- 
sary for  these  cases. 

7.  Organic  heart  disease  with  broken  compensation  is  a  cause 
for  rejection — ^for  the  good  of  the  applicant.  Other  applicants  with 
heart  disease  can  be  very  efficient  in  selected  positions  where  excessive 
physical  strain  is  not  demanded.  In  a  large  group  of  applicants  ex- 
amined for  work  3  per  cent,  were  found  with  heart  disease  but 
only  one-half  of  1  per  cent,  was  rejected.  The  others,  in  selected 
jobs,  made  excellent  employees,  were  very  loyal  because  they  ap- 
preciated the  fact  of  being  employed,  had  a  decreased  sickness  rate 
because  they  were  more  careful  and  were  supervised  more  rigidly, 
and  decreased  labor  turn-over  by  staying  on  the  job  where  these 
advantages  were  afforded  them. 

8.  Hernias  are  a  cause  of  rejection  in  most  of  these  concerns.  This 
is  largely  because  of  the  legal  liabiUties  assumed  by  employing  these 
cases.     This  fear  has  been  exaggerated,  however. 

Men  with  hernias  are  undoubtedly  less  efficient  on  all  jobs  demand- 
ing physical  exertion.  Even  when  a  truss  is  worn  they  unconsciously 
protect  themselves  by  lessened  exertion.  Some  statistics  show  a 
lessened  rate  of  20  per  cent,  in  these  cases.  Considering  the  large 
number  of  hernia  cases  and  the  small  number  of  men  suitable  for 
sedentary  occupations  it  is  obvious  that  many  of  these  cases  must  be 
rejected.  Wherever  possible,  suitable  work  should  be  provided  for 
them. 

Some  arrangement  should  be  made  where  men  with  hernias  could 
undergo  operations.  The  writer  has  operated  a  great  many  of  these 
rejected  cases  free  of  charge  and  then  the  concern,  with  which  he  was 
associated,  would  employ  them  after  recovery.  Such  men  were  able 
to  do  heavy  work  and  were  usually  a  very  loyal  group  of  employees. 
But  this  plan  smacks  too  much  of  charity.  As  an  economic  responsi- 
bility the  state  should  provide  some  means  of  remedying  these,  as 
well  as  other,  conditions  which  have  an  occupational  etiology,  or, 
because  of  their  existence,  have  an  occupational  hazard. 

Undescended  testicle,  varicocele,  hydrocele  and  similar  conditions 
have  often  formed  a  basis  for  rejection  on  the  ground  that  they  pre- 
dispose to  hernia.  Such  conditions  should  not  interfere  with  employ- 
ment except  where  they  form  a  definite  hazard  and  no  proper  work 


380  INDUSTRIAL    MEDICINE    AND    SURGERY 

can  be  selected.  Many  a  man  with  an  undescended  testicle  lying 
in  the  abdomen  has  been  rejected,  who  is  just  as  safe  and  as  capable 
an  employee  as  any  other  able  bodied  man. 

9.  Varicose  veins,  especially  with  ulcers  of  the  legs,  often  so 
incapacitate  a  man  as  to  make  him  unfit  for  emplojrment.  Again, 
a  large  varicosity  adds  to  the  hazards  of  certain  occupations.  Many 
such  cases  must  be  rejected.  But  these  men  on  properly  selected 
jobs,  which  do  not  involve  the  combination  of  heavy  work  and  con- 
tinuous standing,  can  make  efficient  employees.  A  concern,  however, 
always  assumes  the  liability  of  a  shght  injury  to  the  varicose  leg 
causing  a  serious  ulcer  and  prolonged  disabihty.  Relief  from  this 
hability  on  the  part  of  the  compensation  act,  would  enable  more  men 
and  women  with  varicosities  to  secure  employment. 

10.  Severe  deformities,  even  the  loss  of  a  leg  or  an  arm,  should 
not  be  a  cause  for  rejection  if  the  industry  has  work  of  any  kind  that 
could  be  done  by  such  men.  All  concerns  who  have  employed  such 
individuals  testify  to  their  efficiency. 

11.  It  takes  a  very  broad  minded  employer  who  will  consent  to 
the  employment  of  venereal  cases.  The  active  syphihtic  and  acute 
gonorrheal  are  a  menace  to  the  old  working  force.  Therefore  they 
should  be  temporarily  rejected.  But  some  plan  must  be  formed 
whereby  these  cases  can  be  reported  and  forced  to  take  proper  treat- 
ment, and  other  forms  'of  protection  of  society  from  this  menace 
made.  It  is  a  duty  of  the  state  to  take  up  this  problem  at  once. 
A  few  industries  have  provided  proper  care  for  their  employees  who 
contract  these  diseases  but  none  have  assumed  responsibihty  for  the 
diseased  applicant. 

12.  Infected  teeth,  diseased  tonsils,  defective  vision,  lack  of  pro- 
tection by  vaccination  and  other  remedial  conditions  are  not  causes 
for  rejection  by  most  employers.  Some,  however,  have  made  arrange- 
ments, either  in  their  own  medical  departments,  or  with  outside  medical 
and  dental  clinics,  for  the  correction  of  these  conditions.  Employ- 
ment is  granted  on  the  understanding  that  the  apphcant  will  at  once 
seek  proper  treatment.  Some  concerns  even  arrange  a  loan  of  money 
to  these  individuals,  so  that  they  can  obtain  this  treatment;  the  loan 
to  be  repaid  in  small  weekly  payments  taken  from  their  wages.  No 
greater  efficiency  measure,  nor  better  pubhc  health  act,  has  ever 
been  initiated  in  this  country.  One  establishment  has  extended  the 
same  policy  to  venereal  cases. 

SHOULD  DISEASED   CONDITIONS  BE  EXPLAINED? 

When  an  apphcant  is  examined  for  work  and  a  diseased  condition 
is  found  should  he  be  told  about  it?  This  is  a  question  that  has 
caused  considerable  dispute  among  physicians  in  industry. 


MEDICAL   EXAMINATION    OF    APPLICANTS    FOR    WORK        381 

If  we  are  working  solely  for  the  interests  of  the  employer,  and  are 
willing  to  forget  our  responsibility  toward  society,  then  we  may  take 
the  narrow  view  of  this  question.  But,  if  we  are  making  these  ex- 
aminations solely  for  the  good  of  the  old  employees  and  the  applicants 
themselves  and  if  we  are  thorough  and  prove  beyond  a  doubt  that  the 
conditions  really  exist,  we  need  have  no  hesitancy  in  informing  the 
individual  of  his  trouble. 

Some  concerns  forbid  their  physicians  to  ever  tell  an  applicant  when 
a  diseased  condition  is  present.  The  appHcant  is  rejected  by  the  em- 
ployment manager  and  does  not  know  that  it  is  on  account  of  health 
reasons.  He  may  have  a  beginning  pulmonary  tuberculosis  which 
has  not  yet  forced  him  to  seek  medical  advice.  The  doctor  kills  the 
professional  instinct  that  urges  him  to  warn  this  man  of  his  danger. 
The  emploj^er  rejects  him  for  work.  The  man  seeks  employment  else- 
where, exposing  others  to  the  disease  and  allowing  it  to  progress  as 
surely  as  a  smouldering  fire.  He  obtains  employment  in  a  dusty  loft 
and  finally  is  forced  to  quit  work  because  of  consumption.  The 
disease  is  now  incurable.  Doesn't  a  considerable  responsibility  for 
his  death  lie  at  the  door  of  that  physician,  and  the  concern  who  failed 
to  warn  him  when  the  trouble  was  still  curable? 

Many  applicants  with  kidney  disease,  a  heart  condition,  or 
other  incipient  organic  disease,  of  which  they  were  not  cognizant, 
will  thank  the  doctor  for  telling  them  of  the  condition  and  will  seek 
proper  medical  advice  at  once.  But  if  they  are  not  told  they  will  go 
elsewhere  and  seek  employment,  usually  where  physical  examinations 
are  not  required,  and  the  work  here  will  do  the  damage  from  which' 
you  saved  them  in  your  concern. 

There  can  be  but  one  answer  to  this  question.  Every  applicant 
and  every  employee  examined  must  be  kindly  and  diplomatically  told  of 
his  condition  and  given  the  advice  that  will  enable  him  to  seek  the 
proper  remedy.  In  order  to  be  sure  of  his  ground  the  physician  may 
have  to  request  the  appHcant  to  return  for  two  or  three  re-examinations 
and  careful  laboratory  tests.  This  should  be  done  in  every  doubtful 
case  until  the  diagnosis  is  made  or  the  suspicious  findings  proved  false. 
A  concern  whose  doctors  work  thus  carefully  need  never  fear  the 
consequences  of  telling  an  individual  when  a  diseased  condition  is 
present. 

DO  APPLICANTS  OBJECT  TO  EXAMINATIONS? 

The  fear  of  hampering  their  labor  market  was  the  chief  objection  to 
introducing  this  system  into  the  plant  of  the  first  concern  in  Chicago 
that  started  it  on  a  comprehensive  scale.  To  their  surprise,  however, 
they  found  that  applicants  seldom  objected.  A  radical  labor  journal 
made  quite  an  attack  upon  the  system  but  even  this  did  not  increase 


382  INDUSTRIAL    MEDICINE    AND    SURGERY 

objections.  Frequently  the  remark  was  heard  that  "this  must  be  a 
good  place  to  work  if  the  boss  looks  after  the  health  of  his  employees 
this  carefully." 

The  clean,  comfortable  doctor's  office,  the  smiling  nurses,  the 
courteous,  diplomatic  way  in  which  the  doctors  explained  the  pur- 
poses of  the  examination  to  each  one,  soon  impressed  the  applicants 
that  this  practice  was  done  for  their  good  as  well  as  for  the  good  of  the 
old  employees  and  the  employer.  They  told  their  friends  about  it  and 
soon  the  labor  supply  for  this  industry  was  increased  rather  than 
limited.  As  one  mother,  who  had  brought  her  daughter  here  for 
a  job,  said:  "I  would  rather  my  girl  worked  in  a  place  like  this, 
where  she  is  protected  from  disease,  for  $5  a  week  than  to  mingle 
with  people  with  no  telling  what's  the  matter  with  them,  for  $15 
a  week. " 

Out  of  9000  applicants  examined  the  first  year  there  were  six 
who  refused  the  examination.  In  1917  when  jobs  were  plentiful 
there  were  forty  refusals  for  examination  out  of  17000  applicants. 
Sixty  others  refused  or  failed  to  return  for  a  re-examination  when 
some  condition  was  found  that  needed  study. 

The  fact  that  so  many  concerns  have  adopted  the  physical  ex- 
aminations for  appHcants  is  sufficient  proof  that  it  does  not  limit  the 
labor  supply.  This  procedure  must  always  be  done  from  an  un- 
selfish standpoint,  and  governed  by  altruistic  principles,  however, 
or  it  will  in  time  fall  into  disrepute. 

FITTING  DISABLED  TO  JOBS 

The  subject  of  fitting  disabled  men  to  proper  work  for  which 
they  are  qualified  would  fill  a  volume  in  itself  if  the  entire  field  of 
occupations  were  covered.  But  from  a  practical  standpoint  it  in- 
volves just  three  things  which  must  be  considered  by  both  the  physician 
and  the  employment  manager  jointly.     They  are: 

1.  The  nature  of  the  man's  disability. 

2.  His  previous  training  and  occupations. 

3.  The  finding  of  the  occupation  in  the  industry  for  which  the 
above  qualifications  fit  him. 

If  the  doctor  pays  no  attention  to  the  occupations  to  which  handi- 
capped men  are  assigned,  or  if  the  employment  manager  or  foreman 
pay  no  attention  to  the  remarks  of  the  doctor  concerning  the  man's 
physical  condition,  then  no  efficient  system  of  fitting  disabled  to  jobs 
is  in  vogue. 

The  actual  selection,  therefore,  is  a  matter  of  considering  each 
individual  case  in  each  industry.  Every  physician  when  dealing  with 
the  problem  in  its  relation  to  his  specific  industry  will  shortly  find 


MEDICAL   EXAMINATION    OF    APPLICANTS    FOR    WORK         383 

a  number  of  positions  where  handicaps  must  not  be  employed.  For 
instance : 

Never  put  men  who  have  been  poisoned  with  lead,  or  other 
occupational  poisons,  back  where  the  same  hazard  exists. 

Never  place  men  with  organic  heart  disease  in  occupations  where; 
overexertion  could  make  it  worse;  where  a  fainting  spell  could  cause 
injury  to  them;  or  where  they  are  responsible  for  the  lives  of  others, 
as  in  engineering  or  elevator  operating. 

Keep  the  men  with  infected  teeth,  diseased  tonsils  and  other  pre- 
disposing rheumatic  conditions  out  of  dark,  damp  rooms;  where 
exposed  to  extremes  of  heat  and  cold,  and  similar  positions. 

Keep  the  men  with  hernias  off  the  heavy  lifting  jobs. 

A  long  list  of  these  prohibited  jobs  for  men  with  handicaps  should 
be  prepared  by  the  physician  after  a  thorough  study  of  his  industr^^ 
and  should  be  given  to  the  employment  manager  and  every  foreman 
in  the  plant  with  instructions  from  the  head  of  the  concern  that  these 
rules  must  be  obeyed. 

When  a  handicapped  person  has  once  been  assigned  to  a  job  he 
should  never  be  transferred  to  another  occupation  without  the  consent 
of  the  physician  and  the  employment  manager.  To  make  sure  that 
this  rule  is  observed  every  transfer  of  men  should  be  made  only  after 
conference  with  the  employment  department  where  each  man's 
record  is  kept. 

As  a  result  of  the  return  of  so  many  war  disabled  to  industry, 
England  has  had  a  commission  studying  this  problem  for  the  last  two 
years.  This  commission  has  considered  each  occupation  in  the 
majority  of  industries  in  England,  and  has  described  the  jobs  which 
handicapped  men  can  do,  the  training  necessary  to  make  them  com- 
petent in  this  work,  and  what  special  appliances  are  necessary  on 
the  machines  or  on  the  men.  These  reports  are  set  forth  in  several 
pamphlets  which  can  be  obtained  from  His  Majesty's  Stationery 
Office,  London.  They  are  entitled  "Openings  in  Industry  Suitable 
for  Disabled  Sailors  and  Soldiers." 

WHAT  BECOMES  OF  REJECTS? 

The  problem  of  what  is  to  become  of  these  men,  who  because  of 
disabilities  are  refused  work  in  industries,  was  becoming  very  acute 
before  the  war.  With  the  increased  demand  for  labor,  the  result  of 
war  production,  almost  everybody  could  get  a  job,  including  these 
diseased  individuals  who  in  normal  times  would  have  been  rejected. 
It  is  impossible  to  estimate  how  many  of  these  have  sickened  and  died, 
how  many  accidents  they  have  been  responsible  for,  how  much  they 
have  added  to  the  labor  turn-over  situation,  and  to  what  extent  they 


384  INDUSTRIAL    MEDICINE    AND    SURGERY 

have  slowed  up  production.  But  as  industry  settles  into  its  normal 
stride  it  is  evident  that  the  physical  selection  of  men  for  work  is 
an  efficiency  measure  which  is  to  be  utilized  more  than  ever.  How- 
ever, as  the  economic  demand  for  man  power  increases  even  these 
handicapped  individuals  will  be  used,  but  they  will  be  carefully  as- 
signed to  work  in  which  they  can  be  efficient  without  adding  to  their 
disabilities. 

Thus  the  country  is  learning  its  lesson.  Undoubtedly  these 
disabled  men  will  be  provided  for  in  the  future.  These  acts  on  the 
part  of  the  government  are  necessary  to  meet  this  problem : 

1.  Provisions  for  proper  medical  treatment  for  all  diseased  and 
injured  workmen^ — their  physical  reconstruction. 

2.  Provisions  for  proper  vocational  training  in. occupations  which 
they  can  safely  and  efficiently  perform  in  spite  of  their  disabilities. 
Corporation  schools,  continuation  schools,  vestibule  schools,  and 
other  vocational  centers  are  already  meeting  this  problem  in  some 
places. 

3.  Disability,  insurance  to  provide  for  their  maintenance  and  that 
of  their  families  during  these  periods  of  treatment  and  training. 
Adequate  insurance  and  proper  care  in  case  of  permanent  disability. 

4.  Repeal,  by  an  executive  order  in  case  of  disabled  soldiers, 
or  by  state  legislatures,  of  those  portions  of  the  various  state  compensa- 
tion acts  which  now  cause  employers  to  discriminate  against  handi- 
capped man. 

During  the  present  emergency  our  government  is  making  these 
provisions  for  our  disabled  sailors  and  soldiers.  A  wise,  far  visioned 
Congress  surely  will  provide  these  same  advantages  for  the  industrial 
army.  Industry  which  is  so  essential  to  victory  is  disabling  five 
times  as  many  men  and  women  as  the  war.  What  will  we  do  with 
them? 

PERCENTAGE  OF  REJECTS 

Figures  were  obtained  from  eleven  industries  of  the  country  repre- 
senting many  and  varied  occupations,  whose  medical  staffs  are  re- 
puted to  make  very  thorough  examinations  and  where  all  apphcants 
are  said  to  be  examined. 

The  first  five  of  these  concerns  are  known  to  base  their  causes  for 
rejection  on  these  two  points:  first,  whether  the  appHcant  has  any 
condition  that  would  make  his  presence  dangerous  to  the  old  em- 
ployees; second,  whether  he  has  any  condition  that  would  make  work 
of  any  kind  dangerous  to  himself.  Their  percentage  of  rejections 
vary  from  none  to  3.9  per  cent. 

The  remaining  six  concerns  consider  the  above  points  in  reject- 
ing men  plus  the  additional  factor  of  the  added  compensation  lia- 


MEDICAL    EXAMINATION    OF    APPLICANTS    FOR    WORK        385 

bility  if  they  employ  handicapped  individuals.  Their  percentage 
of  rejections  vary  from  9  per  cent,  to  16.76  per  cent. 

These  percentages  give  a  fairly  accurate  index  of  the  number  of 
industrial  workers  in  the  country  who  would  need  to  take  advantage 
of  this  opportunity  for  physical  reconstruction  and  perhaps  train- 
ing for  proper  selected  work. 

As  these  examinations  of  applicants  for  work  represent  the  ap- 
proximate number  of  new  men  employed  it  is  noteworthy  that  those 
concerns  who  have  the  lowest  rejection  rate  as  a  rule  have  the  lowest 
labor  turn-over  rate. 

The  attached  table  gives  the  percentages  of  both  rejected  and  de- 
fective applicants  as  well  as  the  nature  of  the  business  conducted 
by  these  concerns. 

Table  10 


Kind  of  industry 


Number 
applicants 
examined 

in  1916 


Per  cent. 

having 

disabilities 

employed 


Per  cent, 
rejected 
because 

of  disabil- 
ities 


Automobile  factory 

■Garment  industry 

Mail  order  house 

Gas  company,  includes  shops,  street 

gangs  and  office  force 

Grinding  industry 

Engine  and  boiler  foundry 

Electrical  manufacturing  and  muni- 
tion plant 

Rubber  industry 

Implement  foundry 

Electric  power  plant  and  city  office 
force 

Lamp  foundry  and  electric  company .  . 


Total 

number 

of 

employees 


5,000 

33.0 

0.0 

7,877 

0.5 

17,642 

25.0 

3.4 

2,802 

28.0 

3.6 

(6  months) 

2,618 

98.0* 

3.9 

4,475 

9.0 

24,000 

40.0 

14.0 

33,000 

64.9 

14.1 

1,082 

35.0 

15.0 

3,645 

5.0 

15.0 

2,756 

16.76 

35,000 
21,800 
16,000 

4,500 

6,000 
6,500 

18,000 

14,000 

3,300 

5,100 


*  Includes  defective  teeth. 


25 


CHAPTER  XXVI 
EXAMINATIONS  AND  CORRECTION  OF  EYE  CONDITIONS 

With  the  adoption  of  a  thorough  physical  examination  of  em- 
ployees and  of  all  applicants  for  work  it  soon  became  apparent  that  a 
great  number  of  the  cases  had  faulty  vision.  At  first  the  examin- 
ing physicians  would  explain  this  defect  to  the  workman,  pointing 
out  the  lowered  efficiency  and  the  resulting  handicap  to  his  advance- 
ment due  to  lessened  acuity  of  vision,  and  recommend  that  he 
consult  a  recognized  eye  specialist.  Some  followed  the  advice  but 
the  majority  failed  to  do  so  because  "they  couldn't  afford  it,"  "didn't 
know  where  to  go,"  "didn't  want  to  lose  time  from  work,"  or  "could 
get  just  as  good  glasses  at  the  department  store  or  the  corner  drug 
store." 

In  order  to  meet  this  situation  we  arranged  the  following  plan 
for  the  employees  under  our  care: 

1.  All  with  vision  below  20/25  should  be  referred  to  a  competent 
eye  specialist  for  examination  and  necessary  correction. 

2.  Those  needing  glasses  would  be  furnished  the  same  at  cost. 

3.  The  doctor's  fee  and  the  cost  of  glasses  would  be  paid  for  by 
the  firm  in  every  case,  the  employee  repaying  the  firm  in  easy 
installments. 

4.  The  eye  specialist  would  charge  a  very  nominal  rate,  and  could 
afford  to  do  so  because  of  the  bulk  of  work. 

After  adopting  this  plan  it  was  comparatively  easy  to  persuade 
employees  with  defective  vision  to  take  advantage  of  this  opportunity 
of  securing  proper  care. 

Other  concerns  have  had  a  similar  experience  and  have  met  it  in 
various  ways.  Practically  all  agree  that  some  plan  similar  to  the 
above  is  necessary  to  meet  the  great  economic  waste  due  to  this  com- 
mon condition  among  employees — faulty  vision. 

Dr.  Earle  B.  Fowler,  who  has  been  associated  with  the  author  in  the 
night  clinic  on  Industrial  Medicine  and  Surgery,  at  Rush  Medical 
College,  and  has  had  wide  experience  in  this  form  of  industrial  prac- 
tice has  prepared  the  following  brief: 

"Primarily  the  examination  of  the  eyes  and  correction  of  defects 
found  has  been  taken  up  with  the  purpose  of  increasing  efficiency. 
We  have  felt  that  the  employer  would  benefit  by  selection;  by  the 
increase  in  accuracy  and  quantity  of  the  work;  and  Dy  justice  in  the 

386 


EXAMINATIONS    AND    CORRECTION    OF    EYE    CONDITIONS     387 


settlement  of  damage  claims.  The  employee  would,  of  course,  be 
helped  by  the  same  factors;  by  a  careful  placing  so  that  a  defect 
does  not  mean  a  handicap;  by  increased  wage  earning  ability  and 
dependability;  and  by  just  recompense  when  injury  causes  disability. 
"In  the  examinations  of  all  applicants  for  acuity  of  vision  a  nurse 
or  assistant  can  carry  out  the  routine  accurately.  The  distance  must 
be  definite  and  uniform;  the  test  card  evenly  and  brightly  lighted 
with  no  direct  light  in  the  applicant's  eye;  the  vision  must  be  taken  with 
each  eye  singly,  using  the  utmost  care  in  the  covering  of  the  unused 
eye;  there  must  be  two  or  three  test  cards  to  avoid  memorizing  in 
questionable  cases.  The  covering  completely 
of  the  unused  eye  without  causing  pressure  on 
the  globe  has  given  the  most  difficulty,  and  it 
has  been  found  that  the  palm  of  the  patient's 
own  hand  (not  the  fingers),  with  the  margin 
pressed  closely  against  the  nose  gives  the  best 
results  provided  the  applicant  is  forced  to  keep 
his  head  absolutely  straight.  (A  black  card 
may  be  used  in  the  same  manner.)  This  is 
easy  to  control  and  he  must  not  be  allowed  to 
turn  even  slightly  to  right  or  left.  Twenty 
feet  is  the  arbitrary  distance  and  in  places  where 
this  cannot  be  obtained  a  mirror  at  ten  feet 
(fourteen  inch  square  plate)  and  reversed  test 

type  over  the  applicant's  head  is  very  satisfactory,  in  fact  the  ad- 
vantage of  being  able  to  control  the  position  of  the  head  (keeping  it 
straight)  and  at  the  same  time  to  point  to  the  letters,  leads  some  to 
prefer  this  arrangement.  The  eyes  must  be  at  a  uniform  distance  from 
the  card  (or  mirror);  sitting  forward  in  the  chair  results  in  marked 
inaccuracy.  The  record  is  kept  in  terms  noted  on  the  margin  of  the 
test  card  opposite  the  line  of  smallest  type  read.  A  little  urging  will 
often  demonstrate  the  vision  to  be  better  than  indicated  by  the  ap- 
plicant's statement  that  he  can  read  no  farther,  for  many  are  nervous 
and  feel  hurried  or  have  waited  long  and  are  tired. 

"  The  requirements  applied  to  this  selective  test  must  vary  as  judg- 
ment dictates.  It  has  been  found  satisfactory  to  arbitrarily  turn  over 
to  the  surgeon  all  applicants  unable  to  read  the  8/10  (20/25)  line  with 
either  eye  alone  and  leave  it  to  his  judgment  whether  without  cor- 
rection they  will  get  the  best  results  in  the  work  they  are  going  into. 
The  surgeon  may  carry  out  his  work  at  the  plant,  making  the  com- 
plete examination  and  prescribing  glasses  when  deemed  necessary' 
or  the  applicant  may  be  referred  to  his  office  provided  it  is  reasonably 
accessible.  The  problem  of  commercial  supply  of  glasses  may  in- 
fluence in  the  choice  of  arrangements,  the  object  being  to  complete 


Fig.  53. — Snellen's  vision 
test  card. 


388  INDUSTRIAL    MEDICINE   AND    SURGERY 

the  whole  process  with  the  least  delay  in  starting  the  employee  at 
work.  If  there  is  a  reliable  optician  in  the  immediate  neighbor- 
hood or  one  can  be  located  at  the  plant  during  certain  hours  either 
plan  for  the  surgeon's  work  will  be  satisfactory,  otherwise  time  can 
be  saved  by  the  trip  to  the  office  as  there  will  have  to  be  a  day  spent 
in  going  for  the  glasses  anyway.  It  is  most  important  that  the  frames 
be  fitted  individually  with  care  and  accuracy.  As  we  are  caring  for 
people  of  small  salaries  it  is  hard  to  require  an  employee  or  applicant 
for  work  to  spend  the  amount  necessary  for  glasses,  and  in  the  at- 
titude of  the  patient  toward  this  we  meet  one  of  our  hardest  problems. 
Some  firms  arrange  to  buy  the  glasses  and  charge  the  amount  against 
the  employee  for  repayment  in  installments.  Ordering  uniformly 
from  one  concern  will  often  materially  reduce  the  price.  From  the 
point  of  view  of  the  surgeon  the  use  of  mydriatics,  necessary  in  at 
least  a  percentage  of  the  cases,  would  require  much  time  if  working 
at  the  plant  and  if  there  are  too  many  cases  referred  time  can  be 
saved  by  sandwiching  these  in  at  the  office.  Most  of  these  problems 
work  themselves  out  and  the  method  most  advantageous  to  all  is 
reached  in  time. 

"Another  group  of  referred  cases  is  made  up  of  those  employees 
reporting  disability  from  headache,  or  eye  fatigue.  In  most  instances 
a  general  physical  examination  is  made  including  nose  and  throat 
and  then  they  are  referred  for  the  correction  or  elimination  of  visual 
defects.  In  a  large  proportion  of  these  the  vision  at  20  feet  is  normal  or 
better  but  varying  degrees  of  hyperopia  or  hyperopic  astigmatism  are  re- 
sponsible for  the  symptoms.  Muscle  balance  is  carefully  examined 
in  all  of  these.  Added  to  this  group  are  the  employees,  most  often 
from  the  correspondence  or  clerical  departments,  typists  or  comp- 
tometer operators,  reported  for  repeated  errors.  Though  not  a  large 
number  the  results  obtained  with  this  class  have  been  most  important. 

"Cases  of  injury  and  inflammation  will  be  discussed  later. 

"The  question  of  visual  requirements  after  correction  with  glasses 
must  be  left  to  the  judgment  of  the  surgeon.  Definite  abnormal- 
ities must  be  emphasized  in  the  record  so  as  to  be  noted  in  case  of 
transfer  from  one  class  of  work  to  another.  Poor  distant  vision  does 
not  handicap  for  close  work  if  the  near  vision  is  good,  but  would  be  a 
menace  for  one  doing  truck  driving.  Great  reduction  in  the  one  eye, 
a  condition  very  frequently  met  with,  would  lead  to  a  designation  as 
"unsafe"  for  elevator  operator  or  similar  occupation  while  not  in- 
terfering in  another  fine.  Some  famiharity  with  the  work  in  all  de- 
partments is  a  necessary  part  of  the  surgeon's  training  if  he  is  to  make 
these  decisions  with  the  best  results  for  all  concerned. 

"During  the  first  year  of  this  eye  work  at  Sears,  Roebuck  &  Com- 
pany, eye  tests  were  carefully  made  and  the  record  of  vision  kept,  but 


EXAMINATIONS    AND    CORRECTION    OF    EYE    CONDITIONS     389 

it  was  left  to  the  judgment  and  choice  of  the  employee  whether  to 
follow  the  advice  given  regarding  proper  correction.  As  a  result 
out  of  2000  cases  of  defective  vision  found  among  the  applicants  and 
old  employees  only  327  placed  themselves  under  proper  treatment. 

"The  second  year,  April  1,  1916  to  April  1,  1917,  there  were  1834 
referred  of  20,507  applicants,  otherwise  acceptable,  and  in  the  first 
eight  months  of  the  third  year,  April  1  to  January  1,  1918,  1028  cases 
were  referred. 

"A  brief  summary  of  these  cases  gives  some  idea  of  the  need  for 
this  work.  The  results  are  based  on  the  examination  of  2652  em- 
ployees, during  a  period  of  one  year  and  eight  months,  referred  be- 
cause of  defective  vision  or  symptoms  of  eye  strain.  The  records 
total  as  follows: 

1.  Both  eyes  less  than  3^  vision 763 

Of  these  289  were  improved  to  normal,  307  to  better  than 

'^'2,  with  a  prospect  of  further  improvement  as  glasses  were 
worn,  and  12  were  not  improved. 

2.  One  eye  less  than  3^^  vision 662 

Of  these  225  were  improved  to  normal;  318  improved,  but 
not  to  normal;  119  not  improved.  In  most  instances  re- 
corded "  not  improved  "  the  other  eye  was  normal  and  either 

the  prospects  of  improvements  even  with  glasses  were  not . 
good,  or  it  was  felt  the  patient  would  not  wear  glasses  even 
if  supplied.     As  the  one  good  eye  was  sufficient  for  all  re- 
quirements  of  work  the  wearing  of  glasses  could  not  be 
forced.     This  most  important  group  will  be  referred  to  in 
the  last  part  of  the  chapter  in  reference  to  damage  suits. 

3.  Headaches  and  eye  strain 764 

Of  these  493  had  normal  vision,  271  with  reduced  vision 
are  included  in  the  above. 

"Although  detailed  records  of  cases  and  results  at  the  time  of 
fitting  have  been  kept  the  above  is  sufficient  here.  The  hardest  statis- 
tical work  comes  in  the  follow  up.  In  the  opinion  of  department  man- 
agers there  has  been  a  distinct  value  to  the  work.  In  all  instances  they 
have  accepted  our  decisions  in  regard  to  placing  or  transferring  em- 
ployees. The  results  of  this  selection  must  be  speculative ;  conclusions 
in  regard  to  those  in  which  vision  was  bettered  must  also  be  judged  by 
opinions  of  work  improvement.  Those  in  charge  give  many  instances 
of  marked  increase  in  quantity  and  quality  of  the  work  of  these  em- 
ployees either  as  groups  or  individuals.  It  is  comparatively  easy  to 
judge  of  those  reporting  for  eye  strain  or  headaches.  These  results 
have  been  most  gratifying  as  marked  improvement  or  complete  rehef 
is  very  definite.     The  loss  of  time  is  reduced  at  once  to  a  minimum. 


390  INDUSTRIAL    MEDICINE    AND    SURGERY 

"Just  how  much  the  employer  or  the  employee  profits  by  this 
branch  of  the  work  covered  in  this  report  we  cannot  measure,  but  we 
feel  sure  it  is  sufficient  to  more  than  balance  time  and  money  spent. 
Reports  from  other  firms  confirm  this  in  so  far  as  results  can  be  judged 
from  observation   purely. 

"Since  the  employees'  compensation  laws  have  gone  into  effect  it 
has  become  important  for  all  concerned  that  an  accurate  account  of 
vision  of  every  employee  be  kept.  In  the  group  above  in  which  the 
vision  in  one  eye  was  less  than  1/2  normal  60  per  cent,  were  unaware  of 
the  fact  until  the  routine  test  brought  this  out.  Without  a  record  the 
possibihty  of  an  unfair  settlement  following  a  very  slight  or  imagined 
injury  in  any  of  these  cases  is  evident. 

"This  year  a  young  man  applied  for  a  position.  Three  months 
previous  he  had  passed  the  vision  test  for  the  navy.  When  he  came 
to  us  a  low  grade  neuritis  had  reduced  vision  to  0  right  eye,  left  eye 
6/10.  How  easily  it  would  have  been  to  convince  a  jury  that  a  blow 
on  the  head  two  weeks  after  going  to  work  caused  blindness.  Good 
vision,  a  blow  on  the  head,  proven  blindness;  our  peers  do  not  require 
that  pathology  be  presented. 

"Fortunately  the  accidents  are  few.  We  try  to  look  after  all  foreign 
body  cases  and  injuries  immediately  and  follow  up  the  treatment 
until  the  condition  is  healed.  Of  course  it  is  optional  with  the  patient 
whether  he  accepts  treatment  from  the  surgeon  employed  by  the  com- 
pany or  goes  immediately  to  his  own.  Our  only  insistence  here  being 
that  he  sees  someone  we  know  to  be  thoroughly  rehable. 

"If  we  only  take  and  record  vision  carefully  we  have  done  something 
toward  bettering  our  judgment  of  an  employee's  capabihties,  also 
we  have  shown  him  his  deficiences.  We  do  more  if  we  urge  or 
demand  a  correction  of  these  deficiencies,  and  still  more  if  we  help  in 
the  securing  of  the  correction." 


CHAPTER  XXVII 
MEDICAL  TREATMENT  OF  EMPLOYEES 

The  amount  of  medical  treatment  afforded  sick  and  injured 
employees  in  concerns  having  medical  staffs  varies  considerably. 
Most  of  these  take  complete  charge  of  the  treatment  of  all  injured 
employees  when  accidents  are  directly  the  result  of  occupations  or 
plant  conditions.  Likewise  if  a  disease  results  from  occupation  they 
will  assume  the  medical  care. 

Some  refer  all  sick  employees  to  their  family  physicians,  refusing 
even  first  aid  treatment.  Others  render  treatment  in  certain  diseased 
conditions  referring  all  other  cases  to  their  family  physicians,  but 
maintaining  some  form  of  supervision  over  th?  treatment  given  these 
employees.  Still  other  concerns  furnish  complete  medical  and  surgi- 
cal care  to  all. 

In  the  majority  of  cases  most  plant  surgeons  have  been  con- 
scientiously referring  the  sick  employees  to  their  family  physician.  As 
a  rule  they  receive  excellent  care.  But  in  a  number  of  instances 
these  cases  are  neglected,  their  time  loss  from  work  is  greatly  in- 
creased, and  there  is  a  very  decided  financial  loss  to  both  the  employee 
and  employer. 

More  and  more  the  physician  in  industrial  practice  is  being 
called  upon  to  assume  the  entire  medical  care  of  the  employees. 
These  physicians  feel  a  professional  obhgation  toward  their  fellow 
practitioners  and  usually  are  very  conscientious  in  meeting  this 
obhgation.  Nevertheless,  they  are  often  placed  in  an  embarrassing 
position  because  of  their  other  obhgation  to  both  employer  and 
employed. 

The  physician  responsible  for  the  human  maintenance  department 
in  an  industry  must  be  absolutely  honest  and  fearless.  Professional 
ethics  in  its  truest  form  must  he  his  guide.  But  the  old  false  standard 
of  ethics,  which  prevents  a  physician  from  interfering  in  another 
doctor's  case  when  he  sees  the  patient  is  being  neglected,  or  which 
prevents  him  from  giving  an  honest  opinion  to  a  patient  in  order  to 
protect  another  physician's  dishonesty,  should  not  be  confused  with 
true  professional  ethics. 

SUPERVISION  OF  MEDICAL  TREATMENT 
The  advance  which  has  been  made  from  the  days  when  the  company 
surgeon  paid  no  attention  to  the  medical  diseases  of  the  employees 

391 


392  INDUSTEIAL   MEDICINE    AND    SURGERY 

to  the  present  systems  of  supervision  of  their  medical  treatment 
marks  one  of  the  most  progressive  movements  in  industrial  medicine. 
Its  influence  presages  almost  revolutionary  changes  in  the  practice 
of  medicine. 

In  the  well  organized  medical  departments  of  industry  no  employee 
can  remain  away  from  work  on  account  of  sickness  without  the  doctor's 
knowledge.     This  knowledge  is  obtained  through  these  channels: 

1.  An  employee  becoming  sick  at  work  must  secure  a  pass  from 
the  doctor's  office  before  going  home.  He  is  then  reported  on  sick 
leave  every  morning,  by  his  foreman,  until  he  returns  when  he  must 
obtain  a  pass  back  to  work  from  the  doctor. 

2.  Every  employee  who  cannot  come  to  work,  must  send  word  to 
his  foreman  the  morning  of  his  first  day  of  absence.  Those  who  are 
home  on  account  of  sickness  are  reported  to  the  doctor's  office.  In 
the  case  of  an  employee  who  fails  to  notify  the  foreman  there  are 
many  ways  of  ascertaining  the  causes  of  absence.  After  twenty-four 
hours,  if  no  word  has  been  received,  the  foreman  should  send  a  trusted 
employee  to  investigate. 

When  an  employee  is  home  on  account  of  sickness,  the  visiting 
nurse  calls  on  him  within  the  first  three  days  of  his  absence  and 
as  frequently  thereafter  as  his  condition  indicates. 

It  is  her  duty  to  learn  the  nature  of  the  sickness  by  talking  with  the 
family  physician  and  the  family.  She  must  make  sure  that  the 
doctor  is  on  the  job  and  that  every  possible  care  is  being  given  the 
employee.  These  nurses  even  render  such  nursing  aid  as  bathing 
the  patient  and  preparing  certain  foods  (thus  teaching  the  wife  or 
another),  cleaning  up  the  room  and  changing  the  linen  on  the  bed. 
This  is  always  done  with  the  consent  of  the  family  physician. 

These  nurses  soon  develop  a  keen  perception  regarding  the  serious- 
ness of  the  case  and  the  kind  of  treatment  the  patient  is  receiving. 
When,  in  her  judgment,  the  case  is  not  progressing  properly  or  there 
is  evidence  of  neglect  she  reports  the  same  to  the  chief  surgeon. 

Some  member  of  the  medical  staff  then  phones  the  family  physician 
and  arranges  to  visit  the  employee  in  consultation  or  alone.  Any 
suggestions,  such  as  the  employment,  by  the  industry,  of  a  nurse  for 
the  patient,  or  the  sending  of  the  employee  to  a  hospital,  or  the  need 
of  special  consultation,  or  special  treatment,  are  then  made  to  the 
family  physician.  This  is  done  diplomatically,  with  the  knowledge 
that  the  concern  will  pay,  or  loan  the  needed  money  to  the  family, 
for  this  additional  care.  As  a  rule,  the  family  physician  welcomes 
this  interest  in  his  patient.  Only  seldom  is  it  necessary  to  tell  the 
family  that  the  case  is  being  neglected  and  offer  the  services  of  the 
medical  staff. 

The  following  examples  illustrate  this  method  of  supervision: 


MEDICAL    TREATMENT    OF    EMPLOYEES  393 

Mr.  J.  was  reported  absent  on  account  of  sickness  by  his  foreman. 
The  next  day  the  nurse  called  at  his  home  and  found  that  he  was  very 
sick  but  had  not  yet  summoned  his  family  physician.  The  nurse 
secured  his  wife's  consent  and  asked  this  doctor  to  call.  The  following 
day  the  nurse  again  visited  the  patient  and  learned  that  he  had  pneu- 
monia. The  sick  room  was  badly  ventilated  and  dirty.  The  wife  had 
four  small  children  and  no  help,  arid  could  give  very  little  attention  to 
her  sick  husband.  The  doctor  had  only  called  once  and  was  not  to 
return  unless  requested.  The  patient's  condition  seemed  very  serious, 
so  the  nurse  reported  the  state  of  affairs  to  the  chief  surgeon. 

One  of  the  medical  staff,  after  arranging  with  the  family  physician, 
met  the  latter  at  the  patient's  home  within  a  few  hours.  As  a  result 
of  this  consultation,  the  patient  was  removed  into  an  airy  front  room, 
a  nurse  was  put  on  the  case,  the  industry  paying  the  cost,  and  in 
ten  days  the  man  had  passed  his  crisis.  With  the  care  this  man  was 
receiving,  and  would  have  received  in  the  days  prior  to  such  super- 
vision, the  chances  are  he  would  have  died.  He  was  a  valuable 
employee,  was  receiving  two-thirds  of  his  wages  while  away  from  work, 
and  in  case  of  death,  would  have  received  a  death  benefit  from  the 
benefit  association.  It  is  evident  that  from  an  economic  standpoint 
this  was  good  business  on  the  part  of  this  concern. 

Example  2. — Jennie  J.  came  to  the  doctor's  office  on  account  of  a 
severe  pain  in  her  right  side.  Examination  revealed  marked  tender- 
ness over  the  appendix  region.  The  blood  count  showed  16,000 
leukocytes.  A  diagnosis  of  acute  appendicitis  was  made.  The 
family  physician  was  called  on  the  phone  and  asked  if  he  wished  the 
case  sent  direct  to  some  hospital.  He  preferred  to  have  her  sent  home, 
and  promised  to  call  there  Very  shortly.  A  taxi  cab,  therefore,  was 
ordered,  and  Jennie  was  sent  home  with  a  card  giving  the  result  of  our 
laboratory  examination  and  the  diagnosis. 

A  nurse  called  the  next  day  and  reported  back  that  Jennie  seemed 
better,  and  that  her  doctor  had  laughed  at  our  diagnosis  as  she  was 
suffering  only  from  gastritis.  The  attitude  of  the  family  was  hostile  as 
they  felt  we  had  made  a  serious  mistake.  The  following  day  the 
nurse  reported  that  Jennie  was  much  worse.  The  family  doctor 
had  sent  some  other  medicine  out  to  the  house,  but  the  family  did 
not  think  it  necessary  to  have  him  call. 

When  the  nurse  called  the  next  day  she  found  Jennie  suffering  great 
pain,  and  the  abdomen  hard  and  distended.  She  reported  over  the 
phone  to  the  chief  surgeon  that  the  patient  was  being  woefully 
neglected,  and  would  die  unless  some  active  steps  were  taken  at  once. 

The  chief  surgeon  phoned  the  family  physician  and  explained  the 
situation  to  him.  The  latter  still  contended  that  it  was  only  a  case 
of  gastritis.     He  acknowledged  that  he  had  made  no  further  blood- 


394  INDUSTRIAL   MEDICINE    AND    SURGERY 

count.  He  refused  to  meet  the  surgeon  in  consultation,  and  stated 
positively  that  we  had  no  right  to  interfere-  with  his  patient.  A 
request  to  call  on  Jennie  was  then  made  direct  to  the  family.  As 
she  was  receiving  benefits  from  the  association  they  could  not  very 
well  refuse. 

The  examination  made  by  the  company  surgeon  at  this  time  showed 
a  large  appendiceal  abscess  had  developed.  The  blood-count  was 
24,000  leukocytes.  The  condition  was  carefully  explained  to  the 
family,  and  finally  their  consent  gained  for  an  operation.  The 
fact  that  the  surgeon  would  operate  free  of  charge,  and  that  only  the 
hospital  expenses  need  be  met  by  them,  influenced  their  decision. 
While  the  girl  was  being  sent  to  the  hospital  the  father  got  in  touch  with 
the  family  physician.  Just  before  the  operation  this  doctor  appeared 
on  the  scene  and  strenuously  objected.  Consultation  was  called  and 
agreed  that  it  was  an  extreme  case  and  immediate  operation  was 
necessary.     The  father  then  consented. 

At  the  operation  a  large  appendiceal  abscess  was  found  filling 
most  of  the  right  side.  Thorough  drainage  resulted  in  recovery  after 
some  six  weeks.  A  year  later  it  was  necessary  to  operate  on  this  girl 
a  second  time  and  remove  a  gangrenous  appendix  which  could  not 
be  found  in  the  presence  of  the  large  amount  of  pus  at  the  first 
operation. 

The  neglect  of  this  case  resulted  in  an  avoidable  operation  and 
eleven  weeks  of  unnecessary  lost  time  from  work.  This  is  not  an 
unusual  example,  for  every  medical  staff  which  is  properly  super- 
vising the  treatment  of  their  employees  has  had  similar  experiences. 
No  physician  believing  in  true  professional  ethics,  which  must  react 
to  the  welfare  of  both  the  patient  and  the  doctor,  would  condemn 
this  form  of  interference  in  a  case  receiving  such  neglectful  treatment. 

The  number  of  different  forms  of  quackery  which  the  medical 
staff  of  a  large  industry  meets  is  appalling.  Some  of  these  practices 
are  carried  on  by  known  quacks  and  others  by  presumably  reputable 
physicians. 

If  the  plant  doctors  are  honestly  supervising  the  treatment,  they 
must  meet  these  various  forms  of  quackery  with  outspoken  condemna- 
tion and  must  use  every  argument  to  have  the  patient  seek  proper 
medical  care. 

A  sharp  distinction  must  be  drawn  between  quackery  and  certain 
legitimate  forms  of  treatment  which  may  not  exactly  agree  with  the 
views  of  the  medical  staff.  In  the  latter  case  the  physician  should 
never  belittle  the  work  of  the  family  doctor  nor  make  any  disparaging 
remarks  about  his  diagnosis  and  form  of  treatment  in  the  presence  of 
his  patient.  The  profession  soon  learns  to  know  if  the  medical  staff 
of  an  industry  is  at  all  times  square  in  its  judgment  and  statements 


MEDICAL   TREATMENT    OF    EMPLOYEES  395 

to  their  patients  and  the  degree  of  respect  and  co-operation  given 
by  the  physicians  in  a  community  is  influenced  accordingly.  This 
is  important  as  no  system  of  treatment  supervision  can  be  ade- 
quate where  co-operation  with  the  family  physicians  does  not  exist. 

The  following  are  examples  of  pure  or  near  quackery  which  the 
physician  in  industry  is  daily  called  upon  to  meet  and  correct. 

1.  The  Venereal  Quack. — The  methods  of  these  so-called  specialists 
for  men's  diseases  are  notorious.  The  extent  to  which  their  perfidious 
practices  reach  out  and  rob  the  working  classes  of  our  country  surely 
is  not  known,  otherwise  a  government  interested  in  the  welfare  and 
protection  of  its  people  would  long  ago  have  eradicated  this  nuisance 
against  society. 

Cases  of  so-called  gonorrhea  have  been  found  at  examinations 
of  employees,  who  have  been  under  the  care  of  these  quacks  for  months, 
paying  a  dollar  per  treatment  and  receiving  the  same  nightly  from  a 
lay  assistant.  Bacteriological  examinations  of  the  discharge  failed 
to  reveal  gonococci.  Careful  inquiry  revealed  the  fact  that  injections 
of  strong  solutions  of  silver  nitrate,  or  of  nitric  acid  had  developed 
a  marked  urethritis  thus  keeping  up  the  discharge. 

Many  legitimate  cases  of  gonorrhea  are  treated  by  these  special- 
ists and  "cured"  in  two  weeks  for  $25  paid  in  advance.  The  cure 
consists  of  a  drying  up  process.  When  the  recurrence  appears  they 
can  be  "cured"  again  for  $20  paid  in  advance.  Often  these  men  are 
convinced  that  the  recurrence  is  a  new  infection  and  must  therefore 
pay  the  usual  rate  of  $25. 

Men  who  fear  they  have  been  exposed  to  syphiHs,  or  have  con- 
tracted the  disease  go  to  these  quacks.  Heavy  doses  of  potassium 
iodid  are  administered  until  the  typical  iodid  rash  appears  and  then 
it  is  easy  to  convince  the  patient  that  he  has  the  disease.  Many 
cases  have  been  reclaimed  from  the  treachery  of  these  robbers 
and  have  been  relieved  of  the  terror  created  in  their  minds,  by  the 
"museum"  maintained  by  these  quacks  and  the  line  of  talk  handed  out 
by  them. 

Employees  with  harmless  varicoceles  often  consult  these  specialists 
and  are  led  to  believe  that  the  condition  is  serious.  Electrical  treat- 
ments, expensive  "imported"  lotions  and  even  more  expensive  trusses 
or  suspensories  are  sold  to  them. 

The  efficiency  of  empleyees,  hounded  by  the  fears  created  by 
quacks,  and  worry  over  the  debts  the  treatments  involve,  is  bound 
to  be  affected.  The  economic  loss  to  industry  from  this  source  cannot 
be  estimated. 

2.  Patent  Medicine  Quackery.' — This  is  a  more  insidious  form 
of  quackery  and  often  very  difficult  to  cope  with.  An  emploj^ee 
begins  to  lose  weight  and  feels  badly.     He  reads  an  advertisement 


396  INDUSTRIAL   MEDICINE    AND    SURGERY 

describing  symptoms  that  correspond  to  his,  or  the  corner  druggist 
suggests  that  "  swampy-root "  or  "  S.S. "  or  some  other  patent  medicine 
is  just  what  he  needs.  Secure  in  the  behef  that  this  medicine  will 
cure  him  he  takes  a  vacation  to'  rest  up  and  get  in  shape  again.  In 
spite  of  the  four  bottles  of  the  medicine  he  has  consumed  he  grows 
worse  and  finally  returns  to  the  city  and  consults  the  physician  at 
the  plant.  Examination  shows  an  advanced  tuberculosis.  If  he  had 
consulted  a  doctor  in  the  beginning  instead  of  an  ''ad,"  or  a  druggist, 
the  disease  could  have  been  discovered  in  its  incipiency  and  cured. 
As  it  is  the  cure  is  now  accomplished  only  after  a  great  loss  of  time 
from  work,  or  oftener  he  may  not  be  cured  at  all. 

Such  patent  medicines,  frequently  containing  a  high  percentage 
of  potassium  iodid,  have  been  known  to  break  down  tubercles  and 
cause  a  rapid  spread  of  the  disease. 

Many  examples  of  the  misplaced  trust  of  patients  in  patent 
medicines,  and  even  in  drugs  prescribed  by  physicians,  are  constantly 
brought  to  the  attention  of  the  medical  staff  of  an  industry.  This  leads 
up  to  the  third  type  of  quack. 

3.  The  Non-examining,  Non-diagnosing  Type  of  Physician  who 
prescribes  drugs  without  knowing  whether  they  are  indicated  or  not. 
Many  highly  respected  family  physicians  would  be  shocked  to  be 
placed  in  this  category  of  "quacks."  Yet  is  is  hard  to  distinguish 
between  some  of  their  practices  and  those  of  qualified  quacks. 

When  an  employee  reports  that  he  has  been  home  for  the  last  month 
on  account  of  stomach  trouble,  taking  three  kinds  of  medicine  from 
Dr.  J.,  his  family  physician;  when  on  careful  inquiry  you  find  that 
this  doctor  has  never  examined  the  patient;  and,  when  your  examina- 
tion reveals  a  pulmonary  tuberculosis  as  the  true  condition,  it  is  only 
human  to  condemn  such  a  hit  and  miss  method  of  prescribing  drugs. 

One  of  the  commonest  examples  of  this  type  of  quackery  is  the 
giving  of  medicine  to  a  patient  for  "kidney  trouble."  The  physician 
at  the  plant  examines  the  urine  but  finds  no  sign  of  kidney  disease. 
On  inquiry  he  learns  that  the  family  physician  has  never  even  secured 
a  specimen  of  the  patient's  urine. 

Frequently  an  employee  reports  to  the  office  with  a  severe  attack 
of  appendicitis.  He  gives  a  history  of  having  had  a  severe  pain 
in  his  abdomen  the  night  before.  He  went  to  his  family  doctor  and 
was  given  some  powders  to  relieve  the  pain  and  was  ordered  to  take 
a  dose  of  salts.  No,  the  doctor  did  not  examine  him.  When  this 
physician  is  called  on  the  phone  and  told  that  his  patient  has  an 
acute  appendix,  he  often  replies,  ''Well  I  was  afraid  that  was  the 
trouble  last  night."  I  never  hesitate  to  frankly  tell  such  a  doctor 
that  his  neglect  to  examine  the  case,  and  the  drugs  which  he  prescribed, 
jeopardized  his  patient's  life.     Neither  do  I  hesitate  to  take  this 


MEDICAL   TREATMENT   OF    EMPLOYEES  397 

patient  away  from  his  doctor  and  either  refer  him  to  some  competent 
surgeon,  or,  if  he  is  not  able  to  pay  for  proper  service,  to  perform  the 
operation  myself  free  of  charge. 

The  examples  of  this  blind  treatment  of  disease  without  a  thorough 
examination  and  diagnosis  are  so  frequently  bjought  to  the  attention 
of  the  surgeon  who  is  supervising  the  health  of  employees,  that  too 
much  emphasis  cannot  be  laid  upon  this  treacherous  and  dishonest 
practice.  Whenever  such  a  case  presents  itself  it  is  the  duty  of  the 
plant  surgeon  to  tell  both  the  employee  and  his  physician  that  examina- 
tions are  essential  to  the  proper  treatment  of  disease.  This  frankness 
has  been  known  to  influence  some  family  physicians  to  improve  their 
standards. 

Every  teacher  of  medicine  should  impress  his  students  with  this 
great  need  of  proper  diagnosis  of  every  case  before  prescribing  drugs. 
A  state  law  providing  for  the  thorough  examination  of  every  sick 
person  by  a  physician  before  drugs  are  prescribed  and  further  pro- 
viding that  no  kind  of  drugs  can  be  dispensed  except  on  the  prescrip- 
tion of  a  physician,  would  be  one  of  the  greatest  measures  for  the 
conservation  of  man-power  which  could  be  adopted.  It  would  at 
once  do  away  with  "counter  prescribing"  by  druggists,  with  the  sale 
of  patent  medicines,  and  would  eliminate  the  doctor  who  sits  at  his 
desk  and  hands  out  prescriptions  or  medicines  with  barely  a  glance 
at  his  patient. 

To-day  with  so  many  physicians  in  the  army  it  behooves  the 
government  to  take  adequate  steps  to  prevent  the  increase  of  quackery 
and  of  patent  medicine  sales  which  is  bound  to  flourish  because  of  the 
scarcity  of  competent  medical  men.  This  should  be  a  war  measure 
for  health  conservation. 

4.  Hernia  Quacks. — In  many  cities  there  are  so-called  specialists 
who  cure  hernias  by  a  bloodless  operation.  The  men  who  patronize 
such  quacks  are  most  often  met  among  employees  in  our  industries. 
This  operation  as  a  rule  consists  of  the  injection  of  paraffin  into  the 
inguinal  canal.  I  have  later  operated  on  a  number  of  such  cases. 
This  form  of  treatment  of  hernia  is  a  failure  and  a  waste  of 
the  employee's  money  and  every  man  with  hernia  should  be  warned 
against  this  method. 

5.  Belts,  supports,  braces,  plates  and  other  appliances  make  up 
another  form  of  quackery  which  is  frequently  perpetrated  on  workmen 
as  well  as  others.  Too  often  after  abdominal  operations  expensive 
belts  are  sold  to  these  people  who  can  ill  afford  this  additional  expense. 
Experience  in  hundreds  of  cases  of  abdominal  operations  has  proven 
that  only  in  exceptional  instances  are  these  belts  needed.  When 
used  they  tend  to  make  the  patients  over-cautious  about  exercising 
or    exerting  themselves,   and  frequently  prolong  the  length  of  dis- 


398  INDUSTRIAL    MEDICINE    AND    SURGERY 

ability,  I  have  found  a  belt  necessary  in  only  two  out  of  three 
hundred  cases  of  herniotomy. 

The  majority  of  surgeons  would  undoubtedly  scorn  accepting 
a  commission  for  belts  sold  their  patients,  yet  we  all  know  that  the 
prescribing  of  these  post-operative  belts  is  too  often  done  for  the  25 
per  cent,  commission  paid  the  surgeon  or  the  hospital,  instead  of 
offering  real  service  to  the  patient. 

The  need  for  braces  and  supports  should  be  carefully  determined 
before  a  physician  prescribes  these  expensive  appliances.  In  a  few 
cases  employees  have  applied  to  the  Employees  Service  department 
for  a  loan  in  order  to  buy  some  such  appliance.  The  case  is  examined 
thoroughly  by  the  plant  physician  and  then  the  question  of  the  need 
for  this  brace  is  taken  up  with  the  employee's  doctor.  Several  times 
this  has  resulted  in  a  saving  to  the  employee  of  $40  or  more  for  the 
apphance.  Plates  for  flat-feet  are  often  sold  to  people  without  any 
effort  being  made  to  correct  the  faulty  type  of  shoes  worn.  Often 
these  plates  are  bought  on  the  suggestion  of  some  shoe  salesman  or  of  a 
druggist*.  In  too  many  cases  this  is  a  needless  expense  as  the  type  of 
plate  bought  does  not  correct  the  trouble. 

The  useless  expenditure  of  money  by  employees  for  these  various 
appliances  is  one  of  the  commonest  conditions  which  the  medical 
staff  encounters.  Electric  belts,  electric  pads  for  the  shoes,  porous 
plasters,  flannel  jackets,  chamois  vests  and  innumerable  other  con- 
traptions come  in  this  category  of  appliance  quackery. 

A  large  mail  order  house,  which  installed  this  comprehensive 
system  of  health  supervision  of  employees,  including  condemnation 
of  all  forms  of  quackery  and  of  patent  medicines,  gives  an  excellent 
example  of  a  concern  ''practicing  what  it  preaches."  The  writer 
was  told  to  go  over  their  drug  catalogue  and  cross  off  every  patent 
medicine  and  every  appliance  which  they  were  selling  which  could 
in  any  way  be  detrimental,  or  of  no  value,  to  the  buyer.  As  a  result 
this  concern  dehberately  ceased  to  sell  patent  medicines  thereby  cut- 
ting off  profits  amounting  to  $180,000  a  year.  It  retained  for  sale 
only  those  drugs  commonly  used  as  household  remedies  such  as  castor 
oil,  Epsom  salts,  soda  bicarbonate,  etc. 

If  all  manufacturers  and  retailers  of  the  obnoxious  types  of  patent 
medicines  would  voluntarily  adopt  such  a  principle  the  effect  on 
the  health  of  the  nation  would  be  incalculable.  In  the  absence  of 
voluntary  action  some  legal  action  should  be  taken. 

The  medical  staff  which  is  responsible  for  the  supervision  of  the 
medical  treatment  of  employees  must  in  every  case,  first,  determine 
if  the  best  possible  treatment  is  being  given;  second,  if  all  adjuncts 
which  will  help  hasten  the  patient's  recovery  are  being  used  and  if  not, 
see  that  the  concern  provides  these  when  the  family  cannot  afford  to  do 


MEDICAL    TREATMENT    OF    EMPLOYEES  399 

so;  third,  if  interference  in  the  treatment  of  the  case  is  necessary;  fourth, 
advise  the  employees  against  the  wrong  Une  of  treatment,  against 
quacks  the  use  of  patent  medicines  and  all  other  forms  of  quackery; 
and  fifth,  use  every  means  of  educating  the  employees  to  a  knowledge 
of  what  constitutes  proper  medical  treatment.  The  employee  who 
once  learns  this  will  demand  more  scientific  care  from  his  physician. 

WHAT  CASES  SHOULD  BE  TREATED? 

Granting  that  the  medical  staff  of  an  industry  is  to  refer  all  cases  of 
sickness  that  rightfully  belong  to  the  family  physician,  then  what 
cases  should  this  staff  treat? 

The  real  purpose  of  an  industry  in  establishing  an  expensive  med- 
ical system  is  to  reduce  the  amount  of  sickness  and  injuries  among 
its  employees,  and  to  reduce  the  amount  of  lost  time  from  work  to 
a  minimum  when  these  do  occur.  It  is  purely  a  business  proposi- 
tion with  them.  However,  due  largely  to  the  influence  of  their  physi- 
cians, they  recognize  the  claims  of  the  family  physician  and  the  rights 
of  employees  to  choose  their  own  doctor. 

But  in  many  cases  better  results  are  obtained  and  there  is  less 
financial  loss  to  the  concern  if  they  take  complete  charge  of  the  treat- 
ment. Again  they  feel  that  their  responsibility  toward  the  working 
force  and  society  in  general  has  a  greater  claim  on  them  than  the  rights 
of  any  individual  physician  and  for  this  reason  they  assume  the  care 
of  certain  types  of  cases.  In  other  instances  they  demand  that  em- 
ployees undergo  certain  forms  of  treatment  in  order  to  improve  their 
health  and  make  them  more  efficient,  and  therefore  it  is  the  employer's 
duty  to  see  that  proper  treatment  is  rendered  them. 

As  the  medical  staffs,  by  their  work,  have  demonstrated  the  value 
of  proper  treatment  in  these  various  types  of  cases,  it  is  only  natural 
for  the  management  to  demand  that  this  treatment  be  given.  This 
is  not  written  in  defense  of  the  practice  but  rather  to  show  the  pro- 
fession at  large  why  it  is  done. 

1.  Treatment  is  given  by  the  company  surgeons  to  all  injured 
employees  when  their  work  is  responsible  for  the  injury.  The  sur- 
geon, trained  in  emergency  surgery,  and  responsible  to  the  manage- 
ment for  results,  as  a  rule  gives  more  active  treatment,  gets  the  em- 
ployee back  on  the  job  quicker,  and  strives  to  return  him  with  the 
best  possible  restoration  of  function.  The  cost  of  this  surgical  care 
is  less  to  the  concern  than  if  these  cases  went  to  outside  surgeons. 
It  has  proven  a  good  business  proposition  to  the  industry. 

A  great  number  of  employees  are  injured  at  home.  Many  would 
neglect  the  injury  if  compelled  to  pay  a  doctor's  fee  for  the  dressing 
of  what  seems  to  them  a  trivial  wound.     These  cases  can  be  treated 


400  INDUSTRIAL    MEDICINE    AND    SURGERY 

in  the  doctor's  office  and  complications  with  loss  of  time  from  work 
avoided  in  many  instances. 

2.  Employees  with  certain  diseased  conditions  are  dangerous  to 
the  rest  of  the  working  force.  The  tuberculous,  the  syphilitics,  and 
those  with  acute  contagious  diseases  are  examples. 

Some  concerns  seek  out  these  tuberculous  employees  and  forbid 
them  working  in  the  plant.  It  would  be  an  injustice  to  these  sick 
employees,  and  to  society  at  large,  if  they  were  discharged  outright. 
Therefore  these  concerns  have  assumed  the  responsibility  of  giving 
such  cases  proper  sanitorium  care,  paying  all  their  expenses,  and  often 
providing  an  allowance  to  the  family  during  the  absence  of  the  wage 
earner.  No  better  safeguard  to  the  public  health  of  a  community 
can  be  conceived,  and  certainly  no  family  physician  should  object 
to  the  treatment  of  these  cases. 

Most  employers  discharge  all  active  venereal  cases  on  the  ground 
of  protecting  the  old  force.  One  or  two  concerns  have  adopted  the 
same  policy  in  these  cases  as  for  tuberculosis,  and  are  providing 
proper  treatment  for  them,  while  at  the  same  time  steps  are  taken  to 
protect  others  from  infection.  Careful  treatment  combined  with 
proper  selected  work,  hastens  their  recovery  and  prevents  compli- 
cations. This  is  a  direct  financial  gain  to  the  employer  whereas 
the  old  plan  meant  undue  loss  of  time  or  expensive  labor  turn-over. 

Close  co-operation  between  the  municipal  health  departments  and 
the  medical  staff  in  the  case  of  acute  contagious  diseases  has  resulted 
in  better  control  and  better  care  for  these. 

3.  Employees  with  bad  teeth,  diseased  tonsils,  uncorrected  defect- 
ive vision  and  many  other  conditions  are  often  inefficient  workers 
because  of  the  undermining  of  their  health.  When  these  are  found 
the  medical  staff  offers  to  take  care  of  them  free  of  charge,  or  provides 
for  their  care  by  some  specialist  employed  for  the  purpose.  Often 
money  is  loaned  to  employees  to  pay  for  this  service  and  the  company 
dentist  or  the  doctors  arrange  for  some  specialist  in  the  community 
to  give  the  necessary  treatment  at  a  stipulated  fee,  usually  less  than 
would  ordinarily  be  charged.  The  correction  of  these  conditions 
is  good  business  on  the  part  of  the  industry,  and  better  results  demand 
that  the  medical  staff  take  charge  or  supervise  this  treatment. 

4.  In  a  large  industry  many  employees  will  be  found  with  conditions 
which  are  being  neglected  because  of  lack  of  funds  to  provide  proper 
treatment.  Many  of  these  concerns  have  arrangements  with  hospitals 
whereby  cheaper  hospital  care  can  be  obtained.  Such  cases  are  there- 
fore sent  to  these  hospitals  and  operated  free  of  charge  by  the  com- 
pany surgeon  rather  than  sending  them  to  the  city  or  county  hospitals 
for  free  treatment. 

5.  The  types  of  medical  cases  requiring  treatment  which  predomi- 


MEDICAL   TREATMENT    OF    EMPLOYEES  401 

nate  are  the  minor  ailments  which  develop  while  at  work.  The 
employee,  after  being  examined  and  ruling  out  a  more  serious  condi- 
tion, can  often  be  relieved  by  prescribing  some  medicine  and  a  few 
hours  rest  in  the  rest  rooms  provided  for  this  purpose.  Others  must 
be  sent  home.  Whenever  medicine  is  prescribed  for  cases  going  home 
a  statement  as  to  the  drug  used  should  be  sent  with  the  patient  for  the 
family  physician. 

6.  In  certain  industries  there  are  specific  diseases  the  direct  result 
of  the  occupations,  as  for  example  lead  poisoning,  occupational 
dermatitis  and  furunculosis.  These  are  treated  by  the  company 
physicians  the  same  as  all  accident  cases,  or  at  least  should  be. 

The  treatment  of  these  six  different  groups  of  cases  combined  with 
proper  supervision  over  the  treatment  afforded  by  the  family  physi- 
cians make  up  the  bulk  of  the  remedial  work  which  the  medical  staffs 
of  most  industries  carry  on. 

COMPLETE  MEDICAL  TREATMENT 

For  many  years  we  have  had  examples  of  the  medical  staffs  of 
certain  industries  rendering  all  medical  care  to  employees  and  to  their 
families.  This  practice  has  chiefly  been  in  vogue  in  the  mining 
and  lumbering  companies  of  the  west.  It  is  also  a  common  practice 
in  northern  Michigan.  Practically  all  of  these  plans  involved  the 
payment  of  from  $1  to  $5  a  year,  by  the  employee,  into  the  medical 
fund.  This  assured  him  free  treatment  for  a,  year.  It  also  included 
free  treatment  for  the  family  with  the  exception  of  certain  operations 
and  obstetrical  cases  for  which  a  small  additional  charge  was  usually 
made. 

This  type  of  practice  in  many  instances  was  excellent.  The  best 
qualified  surgeons  took  the  positions  and  developed  an  efficient  staff  of 
assistants.  Unfortunately  in  too  many  places  the  doctor  tried  to 
increase  his  income  by  cutting  down  on  the  number  of  assistants. 
It  was  impossible  for  him  to  render  the  most  efficient,  scientific 
treatment  to  the  great  number  of  people  depending  on  him.  A  very 
mediocre  form  of  medicine  was  practised.  This  lowered  the  reputa- 
tion of  this  form  of  contract  work. 

Fortunately  some  of  these  concerns  have  awakened  to  the  value 
of  the  best  preventive  measures  combined  with  the  best  treatment. 
They  have  provided  excellent  hospital  facilities  and  have  very  com- 
petent staffs.  In  such  places  the  treatment  afforded  to  the  employees 
and  their  families  is  of  the  best.  The  old  type  of  contract  practice, 
which  is  condemned  by  all,  is  being  eradicated  by  this  new  era  of 
industrial  medicine. 

The  Brooklyn  Rapid  Transit  Company  affords  an  example  of  a 
concern   that  has  adopted   all  the   modern  principles   of  industrial 

26 


402  INDUSTRIAL    MEDICINE    AND    SURGERY 

medicine  and  surgery  and  has  extended  it  to  include  free  medical 
care  for  its  employees.  They  claim  that  practically  95  per  cent,  of  their 
people  use  their  medical  staff  altogether  and  that  time  loss  on  account 
of  sickness  has  been  reduced  to  a  large  extent.  Above  all,  they  assert 
that  these  measures  introduced  for  the  welfare  of  their  working  force 
have  paid  the  greatest  dividends  in  increased  loyalty  on  the  part  of  em- 
ployees. As  an  example  of  loyalty  the  men  of  this  concern  were 
the  only  ones  who  refused  to  walk  out  during  the  street  railway  strike 
in  Greater  New  York  a  few  years  ago. 

TYPES  OF  CASES  CAUSING  TIME  LOSS 

The  diseases  which  cause  loss  of  time  from  work,  and  therefore 
need  medical  treatment,  will  vary  considerably.  In  a  plant  where 
no  health  supervision  has  been  conducted  many  more  cases  of 
chronic  disease  will  be  found.  For  instance  tuberculosis  made  up 
from  1.5  per  cent,  to  2  per  cent,  of  the  total  causes  for  lost  time, 
whereas  after  several  years  of  careful  supervision  this  disease  only 
accounted  for  0.3  per  cent,  of  the  causes,  in  the  author's  experience. 
The  reduction  of  lost  time  on  account  of  heart  disease  after  health 
supervision,  proper  selection  of  work,  and  adequate  treatment  is  pro- 
vided for  such  employees,  is  a  striking  example  of  the  benefits  of  this 
work. 

The  minor  ailments  which  cause  loss  of  time  are  the  most 
difficult  to  control.  Nevertheless  in  these  cases  improvement  in 
sanitary  conditions,  plenty  of  recreation  for  the  employees,  good  water 
supply  and  the  training  of  employees  to  drink  plenty  of  water,  educat- 
ing them  to  correct  their  diet  and  depend  upon  food  rather  than 
cathartics  to  keep  their  bowels  active,  and  steps  to  prevent  fatigue, 
have  all  caused  a  reduction  in  loss  of  time. 

In  a  working  force  of  twelve  thousand,  divided  approximately 
into  five  thousand  girls  and  seven  thousand  men  the  annual  time  loss 
on  account  of  sickness  was  estimated  at  six  days  per  employee.  There 
were  fifteen  thousand  two  hundred  and  forty-four  cases  of  lost  time 
from  work  among  girls  and  six  thousand  four  hundred  and  twenty 
cases  of  lost  time  among  the  men. 

The  ailments  which  caused  this  lost  time  can  be  classed  as  minor 
and  serious.  The  minor  ailments  were  often  undiagnosed,  as  the 
employees  simply  remained  at  home  and  on  their  return  gave  some  in- 
definite symptom  or  homely  diagnosis  which  they  had  made  them- 
selves. These  common,  everyday  bad  feelings  which  you  and  I  have, 
and  for  which  a  doctor  is  seldom  consulted  come  under  this  group. 
The  attached  table  is  of  interest  as  it  shows  the  diseases  in  a 
large  industry  most  responsible  for  time  loss. 


MEDICAL    TREATMENT    OF    EMPLOYEES 


403 


Table  IL 

DISEASES  CAUSING  TIME  LOSS 

Number  of  Employees 

Male 7,000 

Female 5,000 


Total 12,000 


Cases  of  Lost  Time 


Male . . . 
Female . 


6,420 
L5,244 


Total 21,664 


Minor  conditions 


Female 


Per 
cent. 


Male 


Per 
cent. 


1.  Headache 

2.  Dysmenorrhea 

3.  Colds 

4.  "Grippe" 

5.  Tonsillitis 

6.  Nausea 

7.  Other  stomach  conditions 

8.  Nervousness 

9.  Neuralgias,  myalgias  and  pains  in  joints. 

10.  Backache 

11.  Stiff  neck 

12.  Eye  conditions 

13.  Ear  conditions 

14.  Fever 

15.  Diarrhea 

16.  Constipation 

17.  Fainting 


3778 

2935 

2251 

1354 

974 

750 

403 

355 

188 

153 

99 

172 

102 

110 

130 

92 

132 


24.0 
18.9 
14.0 
08.0 
06.0 
04.8 
02.6 
02.3 
01.3 
01.0 
00.6 
01.2 
00.6 
00.7 
00.8 
00.6 
00.8 


1255   19.00 


1313 

956 

883 

203 

331 

42 

123 

111 

30 

56 

36 

107 

74 

41 

13 


20.40 
14.80 
13 .  70 
03.10 
05.00 
00.60 
'01.90 
01.80 
00.40 
00.87 
00.50 
01.80 
01.10 
00.60 
00.20 


Serious  conditions 


Female 


Per 
cent. 


Male 


Per 
cent. 


18.  Appendicitis 

19.  Bronchitis 

20.  Heart  trouble 

21.  Kidney  disease 

22.  Pleurisy 

23.  Pneumonia 

24.  Paralysis 

25.  Rheumatism 

26.  Anemic  and  generally  run  down . 

27.  Acute  contagious  diseases 

28.  Typhoid  fever 

29.  Tuberculosis 

30.  Miscellaneous 


48 

27 

8 

4 

9 

2 

1 

90 

34 

32 

1 

19 

1281 


0.300 
0.180 
0.050 
0.020 
0.060 
0.010 
0.007 
0.600 
0.200 
0.200 
0.007 
0.140 
8.400 


35 
45 

2 

4 
24 
12 

1 
122 

4 
32 

1 

15 

505 


0.50 
0.60 
0.03 
0.06 
0.40 
0.20 
0.01 
1.74 
0.06 
0.50 
0.01 
0.23 
7.80 


404  INDUSTRIAL   MEDICINE    AND    SURGERY 

An  industry  with  its  large  group  of  employees  forms  a  great  human 
laboratory— a  veritable  physician's  paradise.  Here  he  can  study  aU 
varieties  of  pathological  conditions,  every  type  of  preventive  measures 
and  the  best  lines  of  treatment  which  will  afford  the  quickest  and 
surest  results.  He  also  gains  an  insight  into  those  social  and  economic 
conditions  which  are  constantly  playing  a  greater  part  in  all  medical 
work. 


CHAPTER  XXVIII  / 

WOMEN  m  INDUSTRY 

THEIR  EMPLOYMENT,  SUPERVISION  OF  THEIR  HEALTH,  AND 
OTHER  PROBLEMS 

The  fact  that  a  separate  chapter  is  devoted  to  the  problems  related 
to  women  employees  does  not  indicate  that  a  different  standard  of 
health  supervisio-n  must  be  established  for  them.  All  that  has  been 
written  in  other  chapters  relative  to  industrial  hygiene,  physical 
examinations,  treatment  of  disease  and  accidents — in  fact,  the  entire 
field  of  industrial  medicine,  is  applicable  to  women  as  well  as  men 
employees.  Their  employment  in  industry,  however,  presents  a  few 
problems  which  must  receive  special  consi.deration. 

The  present  world  war  has  focused  public  attention  on, the  question 
of  woman's  work  as  nothing  else  has  ever  done.  In  the  pre-war  days 
the  women  were  employed  in  rather  limited  fields,  every  industry 
having  certain  positions  which  were  recognized  by  men  as  rightfully 
belonging  to  them.  Whenever  an  employer  endeavored  to  place 
women  on  work  carried  on  by  the  male  employees  labor  troubles 
usually  ensued.  A  few  women  were  able  to  overcome  these  preju- 
dices and  enter  a  broader  field  of  endeavor,  but  the  majority  con- 
tinued to  work  on  jobs  suitable  to  their  weaker  strength  and  paying 
a  wage  far  below  that  earned  by  the  men. 

Many  labor  leaders  to-day  still  contend  that  it  is  not  necessary  to 
extend  the  scope  of  woman's  work,  that  the  proper  mobilization  of 
man-power  in  this  country  would  result  in  keeping  production  at  a 
maximum.  Nevertheless,  as  our  millions  of  men  are  being  absorbed 
by  the  army  we  see  women  taking  up  the  work  of  these  men  and  in 
most  instances  carrying  on  with  equal,  or  even  greater  efficiency. 

England,  France,  Canada  and  other  nations,  have  been  forced  to 
utilize  women  on  occupations  heretofore  thought  of  only  in  connection 
with  men.  It  is  only  logical  to  foresee  that  our  country  must  do  the 
same. 

In  every  nation  the  slogan  "equal  pay  for  equal  work"  has  been 
adopted  by  the  industries,  and  many  of  the  old  injustices  toward 
women  employees  are  being  corrected.  Exploitation  of  women  in 
industry  is  becoming  a  thing  of  the  past.  This  is  truly  a  "War  for 
Democracy." 

In  many  of  our  well  organized  industries,  for  years  previous  to  the 

405 


406  INDUSTRIAL    MEDICINE    AND    SURGERY 

war,  the  women  employees  have  been  enjoying  comforts  and  con- 
veniences, every  means  for  the  protection  of  their  health  have  been 
provided,  and  a  good  living  wage  has  been  paid  to  all.  But  in  many 
other  concerns,  the  most  deplorable  conditions  existed  and  still  exist. 
Let  us  make  a  comparison. 

The  writer  once  worked  in  two  different  factories  where  great 
numbers  of  women  were  employed.  One  was  a  shoe  factory,  the 
other  a  glass  factory.  In  both  these  the  girls  worked  in  the  same  rooms 
with  the  men.  No  effort  was  made  to  supervise  the  relationship 
between  the  sexes.  Vile  stories  and  obscene  jokes  were  bandied 
back  and  forth,  the  foreman  often  taking  the  lead  in  these  pastimes. 
Proper  toilet  facilities  were  unknown.  Privies,  one  for  men  and  one 
for  women,  but  in  close  proximity,  were  in  use  and  were  filthy  and 
unsanitary.  I  recall  that  the  pits  were  so  unprotected  that  a  drunken 
man  fell  into  one  of  these  one  night  and  was  found  dead  the  next 
morning. 

There  were  practically  no  washing  facilities.  Everybody,  girls 
included,  carried  their  lunches  and  ate  them  in  the  working  places. 
When  a  girl  became  sick  at  work  she  usually  had  to  stop  for  the  day 
and  go  home,  often  walking  a  considerable  distance.  There  was  a 
cot  in  the  corner  where  the  girls  kept  their  wraps,  which  could  be 
used  for  resting  purposes,  but  a  rest  room  as  we  understand  it  to-day 
was  unknown. 

One  of  these  factories  operating  day  and  night  employed  a  force 
of  girls  for  the  night  shift  also'.  The  use  of  suction  fans  or  other  means 
of  removing  the  injurious  dusts  was  unheard  of. 

Only  the  poor  girls  who  had  to  work  could  have  endured  such 
conditions.  And  the  wages  they  received  for  ten  hours'  work  were  far 
below  those  paid  the  men.  It  was  such  standards  as  these  that  caused 
the  gkl  who  must  work  to  lose  caste.  Humane  employers  who  im- 
proved the  working  places  for  our  girls  and  protected  them  against 
those  influences  which  undermined  their  moral  and  physical  well- 
being  were  great  benefactors  to  the  race.  Some  ranks  in  society 
still  retain  their  early  impressions  of  the  girl  who  must  work. 

For  men  to  work  is  honorable.  Work  is  just  as  "honorable  for 
women.  And  to-day  all  classes  of  women,  from  the  poor  who  must 
work  to  the  rich  who  work  for  patriotic  reasons,  are  entering  all  kinds 
of  industrial  occupations.  New  standards  are  being  set  and  a  new 
viewpoint  is  being  obtained  by  society  concerning  woman's  work. 

Compare  with  the  conditions  in  the  two  factories  described  above 
the  conditions  in  factories  in  England  to-day.  We  are  told  that  modern 
factories  have  been  built  in  England  to  produce  many  of  the  essentials 
for  war;,  and  that  if  these  factories  were  joined  together  they  would 
make  a  building  twenty-five  miles  long  and  forty  feet  in  width. 


WOMEN    IN    INDUSTRY 


407 


Women  make  up  a  large  proportion  of  their  working  forces.  Partly 
to  induce  women  to  work,  and  partly  because  they  found  that  such 
things  helped  production,  these  factories  are  equipped  with  everything 
which  will  add  to  the  comfort,  convenience  and  health  of  the  employees. 
Men  and  women  work  in  the  closest  proximity.  But  in  each  depart- 
ment there  is  an  intelligent  forelady  whose  character  and  personality 
is  such  that  she  is  a  constant  stimulus  for  good.  The  moral  standards 
in  these  industries  are  of  the  highest.  Women  are  honored  and  re- 
spected just  as  much,  although  they  must  often  dress  in  trousers  in 
order  to  do  men's  work. 


Fig.  54.- 


-Every  industrial  sanitary  measure  has  been  provided  in  these  new  working 
laomes  in  England. 


The  sanitary  conditions  of  these  plants  have  been  perfected  to  the 
highest  degree  possible.  Every  method  for  the  protection  of  the 
employees,  both  male  and  female,  against  the  dangerous  poisons  found 
in  munition  work  and  all  other  occupational  diseases  have  been 
provided.  Every  modern  washing  and  toilet  facility  has  been 
installed.  Restaurants  and  canteens  are  a  definite  part  of  the 
organization. 

Comfort  rooms  where  the  girls  can  lie  down  and  rest  when  neces- 
sary, and  where  they  can  go  to  relax  during  the  noon  hour  and  rest 
periods  is  now  recognized  as  one  of  the  most  important  provisions  in 
the  working  place.  Arrangements  have  been  made  for  suitable  homes 
for  all  employees,  and  when  girls  must  room,  the  management  has 


408 


INDUSTRIAL    MEDICINE    AND    SURGERY 


supervised  the  selection  of  these  rooming  places.  Many  concerns 
have  provided  dormitories  for  their  girls. 

Suitable  recreation  for  the  employees  is  now  a  definite  part  of  all 
programs  seeking  to  improve  the  conditions  of  the  working  force. 
The  communities  have  entered  into  this  angle  of  war  work  and  provide 
all  kinds  of  entertainments  for  the  girls  similar  to  our  entertainments 
for  the  soldier  boys. 

The  question  of  hours  of  labor  has  been  settled  in  England  because 
it  was  essential  to  find  the  best  solution  of  this  problem  in  terms  of 
maximum  production.     That  country  found  the  greatest  output  ob- 


FiG.  55.- 


-A  good  forelady  makes  segregation  of  men  and  women  employees 
unnecessary. 


tained  when  the  standard  of  eight  hour  shifts  was  adopted.  This  has 
even  been  divided  so  that  employees  work  two  hours,  rest  fifteen 
minutes;  work  two  hours,  thirty  minutes  for  lunch;  work  two  hours, 
fifteen  minutes  rest;  work  one  hour  and  quit.  Not  only  is  such  a 
standard  good  for  girls  but  it  produces  the  best  results  when  applied 
to  men. 

England  was  not  always  thus  kindly  toward  her  women  employees. 
The  same  deplorable  exploitation  of  women  workers  existed  there  as 
has  existed  in  this  country.  But  the  need  for  greater  production 
for  war  purposes,  and  the  presence  of  many  women  who  demanded 
better  conditions,  forced  both  employers  and  the  government  to 
adopt  those  measures  which  both  Industrial  Medicine  and  Industrial 
Engineering  have  been  urging  for  years. 


WOMEN   IN    INDUSTRY  409 

England  will  never  go  back  to  the  old  conditions.  To-day  the 
women  in  America  who  are  so  gallantly  taking  their  places  in  the 
industrial  army  are  unconsciously  forcing  many  changes  in  our  working 
conditions.  Social  and  economic  improvements  are  being  advanced 
fifty,  yes,  a  hundred  years  under  the  stress  of  war.  America  will  never 
go  back  to  the  old  conditions. 

Many  individuals,  committees,  organizations,  and  government 
agencies  have  been  concentrating  their  studies  and  efforts  on  this 
problem  of  "women  in  industry"  since  our  country  entered  the  war. 
The  reports  of  all  these  bodies  should  be  bound  and  given  to  every 
employer  throughout  the  land  and  if  he  is  wise  he  would  read  them 
as  faithfully  as  he  should  read  his  bible.  If  he  has  a  keen  business 
sense  he  would  learn  his  lesson.  Every  physician  in  industrial  practice 
should  hkewise  become  familiar  with  these  reports  if  he  desires  to  keep 
up  with  the  rapid  advancements  which  are  taking  place  these  days. 
Two  of  the  most  valuable  contributions  on  this  subject  are,  "  Women  in 
Industry"  by  Mr.  C.  E.  Knoeffel,  which  can  be  obtained  from  the 
Society  of  Industrial  Engineers;  and  "War-time  Employment  of 
Women  in  the  Metal  Trades"  published  by  the  National  Industrial 
Conference  Board,  15  Beacon  Street,  Boston,  Massachusetts. 

That  the  industries  of  America  will  meet  this  problem  of  emploj^- 
ment  of  women  as  thoroughly  as  England  has  done  is  indicated  by  the 
following  report  of  a  committee  on  Standards  appointed  by  the 
Standard  Practice  Executive's  Club  of  Detroit,  Michigan,  which  repre- 
sents forty  different  concerns : 

"In  order  to  protect  the  women  who  may  enter  industry  at  our 
solicitation  and  to  provide  for  them  fair  working  conditions,  the  Com- 
mittee on  Standards  of  Working  Conditions  submits  the  following 
recommendation : 

"l.  That  the  Recruiting  Committee  investigate  the  applications 
from  married  women  with  children  to  ascertain  if  the  children  are 
properly  cared  for.  Results  of  investigations  to  be  filed  with  the 
Central  Bureau. 

''2.  That  women  be  given  equal  pay  for  equal  work.  While  learn- 
ing they  shall  be  paid  the  flat  day  rate  paid  men  for  the  same  work  or 
operation.  This  recommendation  has  the  endorsement  of  the  Detroit 
Division  of  the  Women's  Committee  of  the  Council  of  National 
Defense,  as  they  passed  a  resolution  to  this  effect  on  May  14,  1917. 
The  committee  understands  that  the  Buick  Motor  Car  Company, 
of  Flint,  Michigan,  is  at  present  paying  women  on  this  basis. 

"3.  Because  of  the  experience  of  England,  where  it  was  found  that 
shorter  hours  resulted  in  more  and  better  work,  we  suggest  that  the 
working  day  for  women  be  limited  to  eight  hours  and  that  the  maxi- 
mum weekly  hours  be  limited  to  forty-eight. 


410  INDUSTRIAL    MEDICINE    AND    SURGERY 

"4.  That  the  following  working  conditions  are  essential: 

"  (a)  Separate  entrances  to  be  provided  for  women  if  practicable; 
if  not,  that  women  be  allowed  to  report  for  work  fifteen  minutes  later 
than  men  and  leave  fifteen  minutes  earlier. 

"  (h)  That  separate  workshops  be  provided  if  possible;  if  not,  that 
there  be  both  a  man  and  woman  supervisor  stationed  in  the  mixed 
departments. 

''  (c)  That  rest  rooms  and  toilets  adjoining  workshops  be  provided 
with  a  matron  in  charge. 

"  (d)  That  a  sufficient  number  of  drinking  fountains  be  installed 
in  each  department. 

''  (e)  That  the  period  for  lunch  be  at  least  forty-five  minutes. 

"  (/)  That  if  possible  a  restaurant  be  operated  on  the  premises; 
if  not,  at  least  a  counter  maintained  where  a  box  lunch  with  hot  coffee 
and  tea  and  milk  can  be  purchased  at  cost. 

*'  (g)  That  provision  be  made  for  rest  periods  during  working  hours, 
their  frequency  and  duration  depending  on  the  nature  of  the  work. 

"  (h)  That  seats  be  provided  wherever  possible  to  avoid  injury  to 
women  by  standing  all  day  at  their  work. 

"  (i)  That  sickness  insurance  be  provided  to  care  for  workers  absent 
because  of  sickness. 

"  (j)  That  workers  on  monotonous  and  tedious  operations,  to  avoid 
undue  fatigue,  be  transferred  from  time  to  time  as  seems  advisable. 

"  (k)  That  there  shall  be  provision  for  first  aid  attention  to  all 
workers. 

"  (l)  That  there  be  first  class  supervision  of  working  conditions 
with  particular  reference  to  safety,  sanitation,  ventilation  and  lighting. 

"(m)  That  some  person  be  delegated  to  act  as  welfare  supervisor 
for  the  plant,  to  whom  women  shall  have  access  and  whose  duty  it 
shall  be  to  have  general  oversight  over  welfare  conditions.  This 
position  might  be  given  to  some  woman  already  in  the  employ  of  the 
company,  in  addition  to  her  other  duties,  but  if  possible  a  trained 
person  should  be  secured  for  this  work. 

"In  setting  up  these  standards  the  committee  feels  that  its  work 
would  be  useless  and  ineffective  unless  a  permanent  committee  was 
appointed  by  the  executives  to  investigate  working  conditions  in  each 
plant  employing  women  to  be  recruited  by  the  special  committee 
organized  for  the  purpose.  Such  a  committee  should  not  only  make  an 
investigation  before  placing  the  women,  but  should  further  make  periodic 
visits  to  ascertain  if  the  standards  are  being  maintained  according 
•to  agreement.  Since  it  is  almost  impossible  to  set  standards  for  first  aid 
and  safety  provisions,  without  an  intimate  knowledge  of  the  size 
and  kind  of  plant  and  hazard  of  the  work,  we  deem  it  advisable  that 
this  permanent  inspection  committee  treat  each  plant  individually 


WOMEN    IN    INDUSTRY  411 

adjusting  requirements  in  each  case  according  to  the  conditions  found 
on  visitation. 

''It  is  further  believed  that  a  physical  examination  should  he  made 
of  each  applicant." 

Every  physician  familiar  with  the  occupational  hazards  to  health 
that  exist  in  industries  realizes  that  the  methods  of  prevention  of  many 
occupational  diseases  have  not  yet  been  perfected.  Most  of  these 
diseases  have  been  studied  from  their  effect  on  men.  With  women 
entering  these  new  fields  new  problems  will  undoubtedly  be  presented. 
Lead  poisoning  is  known  to  be  more  injurious  to  women  than  to  men. 
Will  not  the  same  be  found  true  of  other  occupational  poisonings? 
Industrial  accidents  have  been  more  common  among  the  male 
employees  but  this  is  due  to  the  more  hazardous  occupations  they 
have  been  engaged  in.  With  women  entering  these  new  jobs  the 
accident  rate  is  bound  to  increase.  The  fact  that  they  are  "green" 
at  the  work  will  be  an  etiological  factor  in  increased  injuries.  Is 
it  not  possible  that  complications  following  these  injuries  will  be  more 
serious  and  more  prevalent? 

These  and  many  other  problems  will  follow  the  employment  of 
women  in  men's  work.  While  the  management  and  the  lay  forces 
are  preparing  to  increase  the  comforts  and  conveniences  and  other- 
wise improve  working  conditions  so  that  women  can  be  employed, 
the  medical  staffs  of  these  industries  must  become  more  rigid  in  their 
efforts  to  supervise  the  health  of  these  workers.  The  doctor  must 
carefully  study  the  effect  of  every  new  occupation  upon  women  work- 
ers and  determine  as  soon  as  possible  what  jobs  they  are  fitted  for 
and  what  jobs  they  must  be  absolutely  barred  from. 

The  future  of  the  race  depends  upon  these  women.  No  war  emer- 
gency must  allow  the  wastage  of  our  woman-power  else  defeat  will 
ultimately  be  ours.  A  new  responsibility  rests  upon  the  physician 
in  industry  because  of  the  increased  activities  of  the  women  workers. 

Women  have  always  been  employed  in  many  occupations  where 
medical  supervision  was  indicated  but  where  it  did  not  exist.  The 
small  employer  has  used  his  women  on  work  entirely  too  arduous  for 
them.  The  heavy  farm  work  which  many  women  used  to  perform  has 
been  responsible  for  thousands  of  premature  deaths.  What  workers 
needed  more  careful  supervision,  or  provisions  for  then'  comfort  and 
welfare,  than  the  hard  working  scrub  women  slaving  every  night,  in 
wet  and  filth,  in  our  large  office  buildings  in  the  cities?  Veiy  little 
attention  has  been  paid  to  their  home  condition^,  to  the  hours  of  labor 
which  they  must  work.  Every  medical  dispensary  has  known  this 
prematurely  old  woman,  broken  in  health,  but  very  few  doctors  have 
sought  the  source  of  her  trouble  in  her  occupation. 

So,  during  this  first  year  of  war,  we  have  witnessed  women  enter- 


412 


INDUSTRIAL   MEDICINE    AND    SURGERY 


ing  many  positions  where  medical  supervision  is  unknown.  Con- 
ductors on  street  cars,  elevator  operators  with  long,  closely  confined 
hours,  janitor  work,  railway  section  hands,  loading  of  junk,  coal,  coke 
and  other  material  on  flat  cars,  piling  of  lumber,  firing  stationary 
boilers,  working  in  machine  shops,  and  shoe  stores,  in  cellar  and  lofts, 
these  are  some  of  the  new  occupations  which  these  pioneer  women 
workers  in  men's  jobs  have  entered. 


Fig.   56. — Women    have    replaced    men    in    many    occupations    in    the    munition 

factories. 


Can  they  stand  the  work;  what  are  its  hazards  for  them;  what  of 
the  factor  of  fatigue  and  other  conditions  which  will  predispose  to 
sickness?  How  are  we  to  answer  these  problems  without  the  most 
careful  medical  supervision? 

The  time  has  arrived  when  our  federal  government  must  demand 
the  most  thorough  supervision  of  the  health  of  all  workers— men  and 
women.  After  one  year  of  war  the  nation  has  learned  that  this  great 
industrial  army  is  just  as  essential  to  the  winning  of  the  war  as  our 
military  army.  The  men  and  women  in  this  second  line  of  defense 
must  be  medically  supervised,  furnished  with  the  adequate  medical 


WOMEN    IN   INDUSTRY  413 

and  surgical  care  when  necessary,  and  otherwise  conserved  the  same 
as  the  first  hne  of  defense. 

In  those  industries  where  medical  departments  are  maintained  they 
should  not  be  disrupted  by  the  demand  for  physicians  in  the  army. 
But  such  industrial  clinics  should  be  extended  and  made  a  center  for 
medical  supervision  of  all  workers  in  that  neighborhood. 

For  those  industries  where  no  medical  supervision  has  been  in  vogue 
and  for  the  employees  in  small  concerns,  and  on  the  isolated  jobs, 
there  must  be  established  industrial  clinics  in  every  community  where 
employees  must  be  forced  to  report  for  proper  supervision.  Other 
physicians  must  be  placed  in  the  field  as  inspectors  to  supervise  the 
working  conditions.  All  the  recognized  essential  features  of  industrial 
medicine  must  be  summoned  for  the  protection  of  this  industrial  army, 
and  especially  for  the  protection  cf  the  women  who  are  braving  these 
unknown  dangers  to  help  win  the  war. 

A  federal  plan  of  public  health  service  is  the  only  solution  of  these 
and  the  other  health  problems  confronting  our  civil  population  to-day. 
With  the  medical  forces  of  the  nation  so  depleted  by  the  demands  of 
the  army  provisions  must  be  made  to  utilize  to  the  greatest  advantage 
the  remaining  civilian  physicians.  The  prevention  of  disease  and 
accidents  among  the  industrial  employees  of  the  country  and  their 
families  will  reduce  the  amount  of  curative  medicine  which  must  be 
practised.  The  medical  forces  of  the  country  must  be  mobilized  there- 
fore and  a  certain  percentage  of  the  physicians  must  be  ordered  to  duty 
in  the  industrial  army.  Prevention  must  become  the  slogan  of  the 
medical  profession. 

Choosing  Occupations  for  Women 

Already  women  workers  have  upset  our  preconceived  ideas  of  what 
jobs  they  are  capable  of  holding.  Throwing  off  the  hampering  in- 
fluences of  sex  and  inexperience  woman  has  stepped  forth  into  the 
fields  of  work  hitherto  belonging  only  to  the  realm  of  man.  From 
every  source  testimony  is  coming  that  she  is  making  good.  But  this 
new  freedom  must  be  controlled.  She  must  not  be  allowed  to  enter 
work  which  in  time  will  destroy  her  or  mean  a  premature  breakdown. 

Therefore  every  woman  worker  should  receive  a  careful  physical 
examination  and  the  occupation  should  then  be  chosen  according 
to  her  physical  qualifications.  In  every  case  the  question  of  whether 
she  is  physically  and  mentally  fit  to  do  the  work  and  whether  the 
occupation  will  be  unduly  hazardous  for  her  must  be  answered. 

Some  have  suggested  that  a  survey  should  at  once  be  made  of  all 
positions  available  for  women  and  then  a  board  should  decide  which 
of  these  jobs  she  could  enter  and  from  which  she  must  be  debarred. 
This  boaYd  might  lay  down  some  general  principles  on  this  subject 


414  INDUSTRIAL    MEDICINE    AND    SURGERY 

but  the  real  selection  of  proper  occupations  can  only  be  made  by  con- 
sidering each  individual  case  as  she  presents  herself.  Some  women 
will  be  found  perfectly  able  to  enter  occupations  requiring  heavy 
lifting  or  constant  standing,  while  others  must  be  assigned  to  seden- 
tary work  only. 

The  Physical  Examination 

How  thoroughly  should  this  examination  be  made?  There  is  no 
question  but  that  women  should  be  examined  from  head  to  foot,  the 
same  as  men  are  examined;  a  complete  analysis  cannot  be  made  in 
any  other  way.  But  to  do  this  women  physicians  must  be  employed 
and  the  number  of  these  is  not  sufficient  to  meet  the  demand. 

One  large  industry  employed  two  women  physicians  and  subjected 
every  girl  employee  to  a  complete  examination.  For  three  years 
they  kept  careful  records  of  these  examinations.  The  number  of 
pathological  conditions  discovered  by  this  thorough  system  were  only 
slightly  more  than  those  found  by  the  partial  examinations  in  other 
concerns.  They  have  since  discarded  the  method  as  it  was  very  dis- 
tasteful to  their  girl  employees. 

The  conditions  usually  found  in  healthy  males  by  examining  below 
the  waist  are  hernia;  venereal  disease;  hydrocele,  varicocele  and 
undescended  testicle;  varicosities,  deformities  of  the  extremities; 
flat-feet  and  other  foot  conditions.  Remember  most  employees  ex- 
amined are  apparently  healthy  and  the  examination  is  not  made  for 
the  purpose  of  discovering  some  acute  disease. 

The  proportion  of  these  conditions  found  by  examining  women 
below  the  waist  are  small  compared  with  men.  Hernia  is  rare  in 
women — even  the  femoral  type  which  is  the  commonest  form  found 
in  this  sex. 

Dr.  Schereschewsky  states  that  he  found  one  hernia  in  five  hun- 
dred examinations  of  female  garment  workers.  In  two  thousand 
examinations  of  girl  employees,  where  the  history  of  the  case  indicated 
a  more  thorough  examination,  the  author  found  three  femoral  and 
one  inguinal  hernia.  In  five  hundred  consecutive  examinations  in 
a  gynecological  dispensary  the  author  found  only  five  femoral  or  in- 
guinal hernias  whereas  umbilical  and  ventral  hernia  were  common. 
These  were  chiefly  found  in  older  women  who  had  borne  children. 
Therefore  the  need  of  examining  female  employees  for  hernia  is  not 
sufficient  to  warrant  subjecting  them  to  the  naked  examination. 

Questioning  as  to  whether  they  have  a  lump  or  swelling  in  the 
groin  will  usually  be  answered  in  the  affirmative  by  a  woman  em- 
ployee if  a  hernia  does  exist. 

Venereal  disease  is  often  hard  to  detect  in  women.  I  have  been 
told  by  the  physician  in  charge  of  the  work  in  the  concern  referred 


WOMEN    IN    INDUSTRY  415 

to  above  that  the  percentage  of  venereal  cases  found  by  their  complete 
examinations  were  very  few.  In  our  clinic  we  have  discovered  cases 
of  syphilis  among  the  girl  employees  but  this  was  done  by  the  detection 
of  mucous  patches  in  the  throat  or  the  rash  on  the  body. 

Varicose  veins  are  common  among  older  women  -or  among  the 
married  women  who  apply  for  work.  These  do  not  object  to  the 
physician  examining  their  extremities.  But  the  average  girl  employee 
has  been  protected  from  the  type  of  occupations  which  have  made 
varicosities  more  prevalent  among  the  male  workers. 

Flat-feet  and  other  foot  deformities  can  often  be  detected  by  the 
gait  of  the  employee.  As  girls  have  been  employed  on  sedentary 
occupations,  sitting  most  of  the  time,  it  has  not  been  so  important 
to  examine  their  feet.  But  in  our  clinic  questions  have  been  asked 
concerning  foot  troubles  and  when  indicated  they  have  been  examined. 

Because  of  the  rarity  of  conditions  found  below  the  waist  Hne, 
influencing  woman's  fitness  for  work,  most  physicians  in  industry 
have  limited  their  examinations  to  the  head,  neck  and  chest  coupled 
with  a  careful  history  in  each  case  which  develops  the  need  for  a  more 
complete  examination  in  certain  cases. 

This  partial  examination  can  be  made  by  a  male  physician,  always, 
however,  in  the  presence  of  a  nurse.  In  order  to  make  sure  that  a 
nurse  was  always  present  and  to  safeguard  the  physician  in  case  some 
employee  raised  a  disagreeable  question.  Dr.  A.  M.  Harvey  initiated 
the  plan  of  having  the  nurse  initial  every  examination  record  in  the 
presence  of  the  woman  just  examined. 

For  years  the  author  had  no  woman  physician  on  his  staff  in  a 
plant  where  approximately  5000  girls  were  employed  and  were  fre- 
quently examined.  There  was  seldom  an  objection  raised  to  one  of 
the  male  physicians  examining  a  girl.  All  abdominal  examinations 
were  made  by  either  the  chief  of  staff  or  his  first  assistant.  Girls 
needing  this  more  thorough  examination  were  referred  to  the  chief 
nurse  who  explained  how  and  why  it  was  made  and  then  prepared  the 
girl.  She  covered  the  girl's  body  with  a  sheet  and  the  doctor  was  then 
called  into  the  room.  He  was  very  careful  not  to  unduly  expose  the 
girl,  examining  by  moving  the  sheet  slightly  to  one  side.  No  girl 
was  ever  unnecessarily  embarrassed  and  she  usually  explained  to  her 
friends  how  considerate  the  doctor  had  been. 

Vaginal  examinations  were  never  made  except  when  the  history 
or  symptoms  indicated  the  need.  In  married  women  these  were  done 
as  described  for  abdominal  examinations.  In  the  case  of  single  girls 
they  were  told  by  the  chief  nurse  of  the  need  and  were  asked 
to  bring  their  mother  next  day,  or  a  note  giving  her  consent,  when 
the  chief  surgeon  would  make  the  regional  examination.  Usually  if 
a  girl  had  never  been  examined  vaginally  she  reported  with  her  mother 


416  INDUSTRIAL   MEDICINE    AND    SURGERY 

or  a  close  friend  to  the  hospital  in  the  city  where  the  surgeon  made 
the  examination  under  a  light  gas  anesthetic.  This  facilitated  the 
examination  and  relieved  the  girl  of  the  embarrassment. 

New  physicians,  fresh  from  hospital  or  dispensary  practices,  enter- 
ing this  field  for  the  first  time  will  often  make  the  mistake  of  handling 
these  cases  as  so  much  material  for  study.  They  will  order  a  girl  to 
submit  to  a  regional  examination  as  though  she  was  a  dispensary 
patient  (a  practice  which  should  likewise  be  condemned).  They  are 
even  careless  about  unduly  exposing  her. 

Such  methods  will  always  place  the  doctor  in  a  wrong  light  before 
these  employees  and  will  soon  destroy  the  usefulness  of  the  doctor's 
office.  In  fact  such  methods  should  not  be  tolerated  in  a  dispensary. 
My  first  advice  to  every  new  assistant  is,  "handle  every  case  as  though 
a  hundred  dollar  fee  was  at  stake." 

When  a  lady  physician  was  finally  employed  on  my  staff  she  had 
considerable  difficulty  in  gaining  the  girls'  confidence.  Often  they 
insisted  on  one  of  the  male  physicians  making  the  examination. 
However,  this  doctor  because  of  her  skill  and  her  wonderful  person- 
ality won  a  place  for  herself  in  the  hearts  of  all  the  girls,  which  makes 
her  services  invaluable  now.  Whenever  a  competent,  diplomatic 
woman  physician  can  be  employed  for  the  examination  of  girl  em- 
ployees the  same  should  be  done.  The  professional  standards  should 
never  be  lowered,  however,  just  to  employ  a  woman  doctor  and  certainly 
never  in  the  case  of  your  male  physician.  Men  or  women  who  have 
not  sufficient  training  to  make  a  good  income  at  the  practice  of 
medicine  should  never  be  employed  in  industry  just  because  they  can 
be  obtained  at  a  cheap  salary. 

The  routine  examination  of  girl  employees  should  be  done  as 
follows: 

1.  Secure  careful  history  by  the  nurse.  Only  the  positive  points 
need  be  recorded. 

2.  Nurse  takes  temperature,  pulse,  weight  and  height  and  tests 
the  vision  by  Snellen  method.     Records  these  findings  on  the  card. 

3.  Girl  is  then  taken  to  lavatory  (best  if  next  to  dressing  room) 
and  a  specimen  of  urine  is  obtained.  This  is  placed  in  a  compartment 
basket  with  other  specimens,  duly  marked,  and  carried  to  the  labora- 
tory for  analysis. 

4.  Girl  removes  waist  and  under  vest  and  is  covered  with  a  cape 
made  from  a  sheet. 

5.  She  then  goes  into  the  adjoining  room,  where  the  doctor  and 
nurse  remain  constantly,  and  is  examined.  As  there  is  no  undue 
exposure  of  these  girls  two  can  be  waiting  while  the  doctor  is  examin- 
ing one;  a  sheet  suspended  between  the  waiting  girls  and  the  one 
being  examined  will  add  to  the  privacy. 


WOMEN    IN    INDUSTRY 


417 


The  cape  worn  by  these  girls  (see  Fig.  57)  has  a  large  neck  opening 
and  can  be  pulled  down  over  either  breast  for  the  purposes  of  examina- 
tion, the  other  breast  remaining  covered.  Either  side  of  the  back 
can  be  similarly  examined.  The  sides  of  the  chest  can  be  examined 
through  the  side  openings  of  the  cape.  This  permits  of  examining 
the  entire  chest  as  far  as  the  waist  hne  without  exposing  any  large 
area  at  one  time.  The  nurse  who  is  present  moves  the  cape  for  the 
doctor. 

This  examination  consists  of  (a)  reading  nurse's  findings  on  the  his- 
tory card  and  also  urinalysis;  (h)  examining  eyes,  nose,  teeth,  tonsils 


"e-a,rT.-9>^  m 


Fig.  57. — Illustrating   type  of   cape  used   to   cover   chest  of   girls   during  physical 

examination. 


and  pharynx;  (c)  palpating  glands  of  neck  and  thyroid;  (d)  examining 
heart  by  auscultation  (palpation,  percussion  and  blood-pressure  are  only 
done  when  some  indication  is  found) ;  (e)  percussing  lungs  and  then  ex- 
aminmg  by  auscultation;  (/)  recording  all  findings  on  history  card. 

While  examining  the  lungs  and  heart  both  breasts  can  be  inspected 
for  suspicious  swellings  and  the  girl  questioned  about  these.  When 
indicated  the  breasts  should  be  thoroughly  palpated — usually  through 
the  thin  cape.  While  the  nurse  is  standing  over  the  girl  she  can 
carefully  inspect   the   hair  and  if  signs  of  pediculosis  are  present 

27 


418  INDUSTRIAL    MEDICINE    AND    SURGERY 

she  will  then  thoroughly  examine  the  employee.  Many  cases  of 
pediculosis  have  been   discovered   by   this  method. 

The  doctor  asks  questions  regarding  abdominal  and  extremity 
conditions.  If  in  the  examination,  history  or  the  urinalysis  show 
the  need  of  a  more  complete  examination  she  is  referred  to  the  chief 
nurse.  In  questionable  cases  the  chief  of  staff  is  called  into  the 
examining  room  at  once  for  consultation. 

Many  girls  have  an  anemic  appearance  and  these  should  always  be 
referred  to  the  laboratory  for  a  blood  count.  Those  with  bad  teeth 
are  referred  to  the  dentist.  Defective  vision  cases  are  sent  to  the  eye 
specialist  and  proper  glasses  fitted  or  other  corrections  made. 


Fig.   58.— Examining  a  girl  applicant  for  work.      Note  how  cape  covers  the  chest, 
also  that  nurse  is  present. 

In  the  routine  examination  room  all  that  is  needed  is  a  stool  for 
the  doctor,  a  piano  stool  for  the  girl  being  examined  (this  facilitates 
her  turning  around  quickly),  a  chair  for  the  nurse,  and  a  table  by 
the  side  of  the  doctor  for  his  instruments,  and  for  writing  purposes. 
All  necessary  appHances  should  be  arranged  close  at  hand  for  the 
doctor,  namely  his  stethoscope,  wooden  tongue  depressors,  which  are 
used  only  once,  the  nasal  speculum  and  the  blood-pressure  outfit. 

Many  of  these  girls  are  found  with  conditions  which  need  careful 
study,  or  further  examination.  They  are  told  to  report  for  re-exami- 
nations and  the  time  and  type  of  examination  needed  is  recorded  on 
their  cards.  The  record  room  keeps  a  tickler  system  on  all  such 
cases  and  makes  sure  that  they  report.  This  same  plan  is  used  for 
the  men. 

When  drugs  are  necessary  to  relieve  symptoms  or  conditions  a  note 
to  this  effect  is  made  on  the  history  cards  and  the  nurse  sees  that 
these  girls  are  sent  to  the  drug  room  where  a  nurse  gives  the  medi- 
cine needed.     Prescribing  of  drugs  has  been  reduced  to  a  minimum. 


WOMEN    IN    INDUSTRY  419 

Which  Girl  Employees  are  Examined? 

All  girl  applicants  for  work  should  be  examined  for  the  same 
reasons  set  forth  in  the  chapter  on  examination  of  applicants  for 
work,  namely,  proper  physical  selection  for  the  work  and  protection 
of  old  force  from  contagious  diseases.  The  type  of  work  the  employ- 
ment department  intends  to  employ  the  girl  on  should  always  be 
shown  on  her  history  card  so  that  the  doctor  can  size  up  her  physical 
qualifications  with  this  work  in  mind.  Girls  who  later  are  to  be  tran."?- 
ferred  to  an  altogether  different  occupation  should  be  re-examined. 

Girls  taken  sick  while  at  work  should  come  to  the  doctor's  office 
for  a  pass  home.  Their  case  should  then  be  carefully  analyzed  and 
when  indicated  an  examination  should  be  made.  Likewise,  many 
girls  will  report  to  the  oflfice  sick  who  can  be  later  returned  to  work  by 
a  few  hours  rest  in  the  rest  room.     Many  of  these  must  be  examined. 

On  returning  to  work  after  an  illness  employees  must  report  to  the 
office  for  a  pass  back  to  work.  Those  whose  history  indicates  the 
need  should  be  examined.  In  a  large  industry  this  plan  may  cause 
much  lost  time  from  work  due  to  the  congestion  in  the  doctor's  office 
from  so  many  reporting,  and  the  long  distance  between  the  office  and 
some  departments.  To  obviate  this  loss  a  number  of  substations 
have  been  provided  in  various  parts  of  the  plant  with  a  nurse  in  charge. 

The  employees,  especially  the  girls,  can  report  to  these  for  their 
passes.  Most  of  the  girls  have  been  absent  one  or  two  days  on  account 
of  some  minor  ailment  and  these  can  be  sent  direct  to  work  by  the 
nurse.  Others  the  nurse  will  send  to  the  doctor's  office  for  examination 
before  the  pass  is  issued. 

All  women  employed  in  fatiguing  occupations  or  hazardous  work 
from  the  standpoint  of  occupational  poisonings,  should  be  periodic- 
ally examined.  This  is  one  of  the  most  important  features  of  proper 
health  supervision. 

Rest  Rooms 

Wherever  women  are  employed  clean,  airy  rest  rooms  removed  from 
excessive  noises  should  be  provided.  They  should  be  furnished 
with  single  beds,  instead  of  hard  cots,  with  clean  pillow  and  sheets 
and  warm  blankets.  A  nurse  or  some  qualified  matron  should  always 
be  in  charge.  Screens  should  separate  the  beds  so  as  to  furnish 
privacy  to  each  girl.  Talking  and  other  noises  should  be  prohibited. 
The  room  should  be  kept  cool  and  well  ventilated.  Its  very  appearance 
should  be  restful. 

In  the  author's  early  experience  the  rest  room  was  a  dark  back 
room  of  the  doctor's  office.  Hard  cots,  provided  only  with  a  blanket 
under  and  over  the  girl,  afforded  the  means  for  rest.  When  a  sick 
girl  reported  to  the  office  and  the  nurse  suggested  that  she  lie  do^Ti  in 


420  INDUSTRIAL    MEDICINE    AND    SURGERY 

the  rest  room  instead  of  going  home  she  refused  oftener  than  accepted 
the  invitation.  It  was  only  an  emergency  room  used  by  the  girls 
when  too  sick  to  refuse. 

Later  this  concern  provided  a  large,  airy  room  furnished  with  beds 
as  described  above.  The  girls  with  temporary  sickness  would  report 
to  the  office  and  were  always  glad  to  go  to  the  rest  room,  remove  only 
their  shoes,  or  perhaps  loosen  their  skirts  and  corsets  and  crawl  in 
between  the  clean  sheets  and  under  the  warm  blankets.  The  nurse 
would  then  bring  them  a  hot  water  bottle  and  often  a  hot  drink.  Many 
were  given  a  glass  of  malted  milk  or  a  cup  of  hot  tea.  After  an  hour 
or  so  these  girls  would  feel  better  and  would  return  to  work  (Fig.  59) . 


Fig.  59. — Rest  room  for  women   employees.      Nurse  always  in   charge.     (From 
Doctor's  Office,  Sears,  Roebuck  &  Co.) 

In  the  old  days  girls  who  had  fainted,  had  severe  cramps  with  their 
periods,  had  headaches,  nausea,  diarrhea,  pain  in  their  side,  or  other 
minor  ailment,  usually  went  home  losing  the  greater  portion  of  the 
day  and  often  longer  because  the  exertion  of  going  home  had  made  the 
condition  worse.  With  this  new  rest  room  these  girls  were  restored 
to  work  in  a  short  time,  and  often  more  serious  conditions  were  aborted. 

No  greater  efficiency  measure  can  be  installed  by  a  concern  than  a 
properly  located,  adequately  equipped  rest  room. 

Sitting  Positions  and  Rest  Periods 

Most  state  laws  now  require  that  women  shall  be  furnished  seats 
while  at  work.  None  of  these  laws  seemed  to  take  into  account  the 
deleterious  effect  of  this  constant  sitting.  Our  good  law  makers 
seemed  to  think  they  had  met  their  obligations  toward  those  of  the 
gentler  sex,  who  must  work,  by  gallantly  providing  them  seats. 

Constant  standing  is  undoubtedly  fatiguing  tomost  women  workers, 


WOMEN   IN   INDUSTRY  421 

but  of  the  two  evils  constant  sitting  is  the  worse.  The  congestion 
of  the  pelvic  organs  by  this  practice,  and  the  tendency  toward  con- 
stipation because  of  lack  of  exercise,  causes  many  pathological  con- 
ditions to  develop  in  the  generative  organs  of  women.  The  congestion 
and  constipation  also  tend  to  develop  hemorrhoids.  Backaches, 
pains  in  the  legs  and  many  ill-feelings  can  be  traced  to  constant  sitting. 

The  ideal  work  for  woman  will  enable  her  to  stand  part  time  and 
sit  part  time.  If  she  can  move  about  while  at  work  it  is  even  better. 
In  the  departments  where  the  work  permits  this  I  have  found  at 
least  50  per  cent,  less  absenteeism  on  account  of  dysmenorrhea  than 
in  those  departments  where  the  girls  sat  constantly  at  their  work. 
Fainting,  nervousness  and  signs  of  fatigue  were  also  less. 

Even  before  state  laws  demanded  it,  many  occupations  for  girls 
necessitated  constant  sitting.  For  these,  and  in  fact  for  all  workers, 
rest  periods  should  be  provided.  Ten  or  fifteen  minutes  in  the  middle 
of  the  morning,  and  the  same  time  in  the  middle  of  the  afternoon 
furnish  these  workers  the  opportunity  to  walk  about,  relax  from  the 
tension  of  work,  do  their  visiting  and  gossiping  and  get  rid  of  the 
stored  up  products  of  fatigue. 

The  windows  of  the  working  room  should  be  opened  up  during  such 
a  period,  and  marching,  calisthenics,  games  and  other  forms  of  exercise 
indulged  in.  Music  at  these  periods  from  a  victrola  will  stimulate 
dancing,  and  that  in  itself  is  restful.  The  f orelady  should  devise  means 
to  make  these  rest  periods  of  the  greatest  benefit  to  the  girls. 

Clothing 

The  new  occupations  women  are  entering  are  having  a  marked 
influence  on  their  manner  of  dress.  Overalls  and  trousers  are  common 
wearing  apparel  for  many  women  workers  to-day.  Common  sense, 
thick  soled  low  heeled  shoes  are  necessary  in  many  of  these  positions. 
If  this  influence  will  extend  to  her  sisters  in  the  ordinary  occupations 
of  woman  great  benefits  and  increased  efficiency  will  result. 

The  constant  sitting  regulations  were  largely  necessary  because 
of  the  illogical  shoes  girls  wear  when  working.  It  is  obvious  that  the 
high  Cuban  or  French  heel,  with  the  thin  turned  sole,  or  the  low 
pumps,  were  never  made  to  work  in,  especially  if  the  work  require 
standing. 

If  women  can  be  persuaded  to  wear  shoes  modelled  after  those 
recommended  for  soldiers  they  will  develop  strong  feet  and  will  be 
able  to  qualify  for  many  more  positions  than  have  been  opened  to  them 
in  industry  in  the  past. 

The  high  heeled  shoe,  loose  skirts,  flowing  sleeves  and  other 
peculiarities  of  dress  are  hazardous  in  occupations  about  machinery, 
tending  to  increase  the  accident  rate. 


422  INDUSTRIAL   MEDICINE    AND    SURGERY 

In  departments  where  men  and  girls  work  together  great  difficulties 
in  ventilation  are  presented  during  the  winter  months,  because  of  the 
flimsy  waists  worn  by  girls.  They  are  easily  chilled  when  a  window 
is  opened  and  demand  more  heat  than  is  wholesome  in  the  departments. 

One  of  the  best  services  the  nurses  or  the  woman  advisor  or  welfare 
worker  can  render-  to  a  concern  is  to  correct  these  faulty  dress  habits 
among  the  girl  employees. 

Food 

Every  employee  should  get  out  of  the  working  room  for  the  lunch 
hour,  during  which  time  it  should  be  thoroughly  aired  out.  This  is 
especially  appHcable  where  girls  in  sedentary  occupations  are  employed. 

A  cafeteria  or  restaurant  should  be  provided  where  warm,  whole- 
some food  can  be  obtained.  If  the  number  of  employees  does  not 
warrant  this  then  some  suitable  place  for  the  eating  of  lunches  should 
be  provided.  Here  hot  tea  or  coffee  or  soup  should  be  sold  at  a 
small  price. 

Drinking  and  Toilet  Facilities 

Every  recommendation  for  improving  the  hygienic  conditions  of 
the  working  place  made  in  other  chapters  should  be  adopted  wherever 
girls  are  employed.  Special  mention  is  made  here  of  the  drinking 
and  toilet  facilities  because  there  is  a  tendency  to  neglect  their 
importance. 

When  employees  are  engaged  on  piece  work,  and  especially  in  the 
case  of  girls,  one  often  finds  that  insufficient  water  is  consumed  and  the 
requirements  of  nature  are  neglected.  The  girls  will  simply  not  lose 
the  money  involved  by  taking  time  off  for  these  things. 

The  only  solution  for  this  is  that  the  employer  will  give  ample  time, 
without  loss  to  the  employee,  to  attend  to  these  essentials.  Bubbling 
fountains  should  be  located  near  the  working  places  and  every 
employee  should  be  thoroughly  educated  in  the  importance  of  water 
drinking.  No  better  remedy  is  at  hand  for  the  prevention  of  fatigue 
than  frequent  flushings  of  the  body  organs  by  water. 

For  every  hundred  girl  employees  there  should  be  provided  close 
at  hand  at  least  five  toilets.  The  toilet  rooms  should  be  kept  clean 
and  well  ventilated.  Washing  facilities  should  be  in  the  room,  or 
an  adjoining  room.  Receptacles  for  refuse  are  necessary.  Means 
for  obtaining  sanitary  napkins  should  always  be  present  in  these 
rooms. 

Minor  Diseases  Common  to  "Women  Employees 

From  an  analysis  of  15,244  cases  of  absence  on  account  of  sickness 
(see  Chapter  XXVII)  the  author  found  that  headaches  caused  24  per 


WOMEN   IN   INDUSTRY  423 

cent,  of  the  absenteeism.  Headaches  are  more  common  among  girls 
than  men  and  cause  a  great  loss  to  every  concern  employing  girls. 
The  plant  doctor  should  make  a  careful  study  of  every  case  to  ascertain 
the  cause.  The  condition  is  usually  indicative  of  some  other 
trouble,  the  correction  of  which  will  stop  this  drain  on  efficiency. 

Constipation  is  present  in  many  cases  and  the  cessation  of  head- 
aches on  curing  this  condition  is  a  common  result.  Diseased  tonsils, 
defective  teeth,  and  other  foci  of  infection  about  the  nose  and  throat, 
as  well  as  defective  vision,  are  frequently  the  source  of  headaches- 
These  should  be  carefully  examined,  the  teeth  even  being  x-rayed 
and  any  infected  foci  removed.  Glasses  should  be  provided  whenever 
needed.  The  author  has  operated  free  of  charge  over  one  hundred 
cases  of  infected  tonsils  in  order  to  relieve  employees  of  headaches 
and  thus  improve  their  value  to  the  concern.  Over  a  thousand  cases 
of  defective  teeth  have  been  corrected  for  the  same  purpose  and  has 
resulted  in  at  least  50  per  cent,  of  the  cases  being  relieved. 

Fatigue  poisoning,  faulty  diet  especially  at  the  lunch  hour,  insuf- 
ficient water  drinking,  night  work  at  home  and  many  other  conditions 
either  in  their  work,  in  their  living  conditions  or  in  their  bodies,  have 
been  found  as  the  cause  of  headaches.  The  physician  will  find  that 
in  a  large  percentage  of  the  cases  he  can  run  the  cause  to  earth  by 
diligently  studying  all  possible  sources.  The  value  of  this  work  to 
the  employer  cannot  be  estimated,  but  must  result  in  great  financial 
saving  in  labor  tutn-over  and  great  gains  in  output. 

Dysmenorrhea  came  second  in  the  causes  for  absences,  18.9  per 
cent.  This  condition  as  a  cause  for  reducing  eflaciency  and  making 
irregular  attendance  at  work  has  not  received  sufficient  attention 
from  the  medical  profession.  The  subject  is  dealt  with  in  detail 
further  on  in  this  chapter. 

Rest  periods,  with  relief  from  constant  sitting,  the  urging  of  plenty 
of  outdoor  exercise,  the  relieving  of  constipation  by  proper  diet,  and  a 
suitable  rest  room  for  a  few  hours  rest  when  the  period  starts,  have  all 
resulted  in  a  decrease  in  this  cause  of  absence.  Here  again  the  doctor's 
ingenuity  will  be  tested  in  finding  the  cause  of  the  trouble. 

Colds  ranked  third,  or  14  per  cent.,  in  the  causes  of  absence.  This 
condition  was  20.4  per  cent,  of  the  causes  among  men.  It  is  a  very 
difficult  condition  to  control  and  is  undoubtedly  infectious.  As- 
sociated with  it  are  mild  forms  of  tonsilhtis  and  other  respiratory 
infections.  It  is  much  better  to  send  employees  with  colds  home 
than  to  leave  them  in  the  department  to  spread  the  disease.  But 
employees  with  mild  ''colds"  will  not  report  to  the  doctor's  oflSce 
remaining  in  the  department  as  sources  of  infection  to  others. 

Educational  propaganda  on  the  infectious  nature  of  "colds," 
"grippe,"  and  tonsillitis  will  help  reduce  this  source  of  absenteeism. 


424  INDUSTRIAL   MEDICINE    AND    SURGERY 

The  following  "Don'ts"  should  be  spread  by  letters,  pamphlets,  bulletin 
boards  and  other  means  throughout  the  working  force: 

1.  Colds,  grippe,  tonsillitis  and  often  causes  of  coughs  are  infectious 
and  you  can  spread  these  to  your  fellow  workers. 

2.  DonH  continue  to  work  when  you  have  these  but  report  to 
the  doctor  at  once. 

3.  Don't  talk,  sneeze,  or  cough  into  another  person's  face  especially 
when  you  have  a  cold. 

4.  Don't  jerk  your  handkerchief  from  your  pocket  and  carelessly 
shake  it  before  or  after  using. 

5.  Don't  sneeze  or  cough  without  covering  your  mouth  with  a 
handkerchief. 

6.  Don't  spit  on  the  floor. 

7.  Don't  use  a  common  towel,  drinking  cup,  utensils  or  anything 
that  might  be  the  means  of  spreading  your  cold  to  others. 

8.  Don't  put  pencils,  pens,  envelopes  or  like  things  in  your  mouth. 
If  you  haven't  a  cold  maybe  the  other  fellow  had. 

9.  Don't  fail  to  report  to  the  doctor  early.  Colds  can  often  be 
stopped  by  proper  early  treatment. 

All  employees  reporting  to  the  office  on  account  of  these  respiratory 
conditions  must  be  scrutinized  thoroughly  to  discover  if  he  has  this 
contagious  type.  The  temperature  will  often  be  99^°  to  100°  while 
the  employee  insists  "outside  of  a  bad  cold  I  am  well  and  able  to 
work. "  Those  with  temperature  should  always  be  sent  home.  The 
throat  which  is  inflamed,  often  covered  with  very  small  pearly  papules, 
is  suggestive  of  this  so-called  grippe.  A  severe  headache  and  aching 
all  over  associated  with  a  slight  sore  throat  or  a  "cold"  is  sufficient 
evidence  to  warrant  sending  the  employee  home  to  protect  the  old 
force. 

Often  painting  the  nose  and  throat  with  a  10  per  cent,  solution 
of  argyrol  or  using  an  alkaline  spray  and  repeating  it  several  times 
during  the  day,  with  hot  drinks,  combined  with  a  few  hours  rest  in 
the  rest  room,  the  bed  being  isolated  and  thoroughly  cleaned  after- 
ward, win  serve  to  abort  these  "colds."  When  an  employee,  who  is 
hardly  sick  enough  to  call  his  or  her  doctor,  is  sent  home  instructions 
such  as  the  following  should  be  given : 

1.  Go  home  and  rest. 

2.  Take  a  hot  bath  and  a  hot  lemonade. 

3.  Take  a  dose  of  salts  or  castor  oil. 

4.  Go  to  bed  and  cover  up  warmly. 

5.  Gargle  a  solution  of  one  teaspoonful  of  baking  soda  (Soda 
Bicarbonate)  to  a  glass  of  water  every  two  hours. 

6.  Drink  plenty  of  water ;  also  drink  a  hot  lemonade  every  2  hours 
containing  the  following: 


WOMEN    IN    INDUSTRY  425 

Baking  soda 1  oz. 

Cream  of  tartar 1  teaspoonful 

Sugar f^  oz. 

Lemon  juice 1  oz. 

Hot  water 1  pint 

7.  If  the  cold  has  disappeared  after  twenty-four  hours  you  can 
report  to  the  doctor's  office — otherwise  you  should  summon  your 
family  physician. 

Many  a  serious  illness  with  prolonged  disability  has  been  aborted 
by  these  methods.  The  plant  physician  should  ever  be  on  his  guard 
against  these  epidemics  of  "colds"  or  so-called  "grippe"  which  have 
frequently  disrupted  the  working  forces  in  many  industries. 

Grippe  and  tonsillitis  made  up  8  per  cent,  and  6  per  cent,  of  the 
causes  for  disability  among  the  girls  and  14.8  per  cent,  and  13.7  per 
cent,  of  the  causes  among  the  men.  Thus  "colds"  and  these  two 
conditions  rank  higher  in  the  causes  for  absence  than  any  other 
minor  ailments. 

Stomach  trouble,  nausea  and  cramps,  and  pain  in  the  side  cause 
considerable  of  the  lost  time  from  work.  Girls  will  get  up  in  the 
morning  and  because  they  "don't  feel  like  it"  or  because  they  are 
late  will  rush  off  to  work  without  eating.  About  the  middle  of  the 
morning  they  become  weak,  sick  at  their  stomach  and  are  forced  to 
report  to  the  doctor's  office.  Many  of  these  can  be  relieved  and  sent 
back  to  work.  Often  a  little  food  or  a  glass  of  malted  milk  is  the 
best  treatment  you  can  render. 

These  stomach  conditions,  fainting,  and  nervousness  are  the  com- 
monest manifestations  of  fatigue.  When  a  girl  reports  three  or  four 
times  with  these  conditions  a  careful  investigation  of  her  working 
conditions  will  usually  reveal  the  cause. 

Constipation. — Constipation  is  one  of  the  commonest  complaints 
among  girl  employees  and  undoubtedly  plays  a  very  important  part 
in  the  minor  illnesses  which  cause  short  periods  of  lost  time  from 
work.  In  over  a  thousand  consecutive  records  of  working  girls,  ap- 
proximately 33  per  cent,  give  a  history  of  constipation  and  at  least 
20  per  cent,  of  these  were  more  or  less  habitually  constipated. 

The  cathartic  habit  among  girls  is  more  extensive  than  would 
generally  be  believed.  This  is  especially  true  among  the  foreign 
element  and  the  less  educated,  and  is  undoubtedly  stimulated  by  the 
extensive  advertisements  of  various  kinds  of  laxatives  in  foreign  and 
cheaper  newspapers. 

Girl  employees  are  more  prone  to  use  the  doctor's  office  than  are 
the  men  and  one  of  the  most  frequent  causes  for  their  visits  is  con- 
stipation. The  easiest  way  for  the  doctor  to  handle  these  cases  is 
to  give  them  a  Seidlitz  powder  or  a  pill  but  such  a  method  will  only 


426  INDUSTRIAL   MEDICINE    AND    SURGERY 

serve  to  increase  the  trouble.  For  several  years  I  have  met  this  prob- 
lem by  giving  every  employee  who  complains  of  constipation,  a  printed 
diet  sheet  containing  anticonstipation  foods  which  could  readily  be 
purchased  at  the  restaurant,  could  be  carried  in  the  lunch  basket, 
and  which  could  be  served  at  home.  In  addition  each  case  was  given 
a  prescription  for  a  fruit  mixture  as  follows: 

Figs M  lb. 

Dates M  lb. 

Seedless  raisins ^  lb. 

Cooked  prunes yi  lb. 

Senna  leaves 3^  oz. 

Grind  through  a  meat  chopper  or  chop  up  finely,  mold  into  a 
loaf  and  keep  in  a  cool  place.  Take  one  or  two  teaspoonfuls 
every  night. 

In  one  department  employing  twenty  girls,  I  found  that  70  per 
cent,  of  these  suffered  from  constipation  and  approximately  50  per  cent, 
had  dysmenorrhea.  Efforts  to  overcome  these  two  conditions  were 
concentrated  on  this  group.  The  forelady  secured  a  table  in  a  res- 
taurant where  they  could  all  eat  together  and  insisted  on  the  mana- 
ger of  the  restaurant  serving  the  girls  with  at  least  two  of  the  articles 
mentioned  in  the  constipation  diet  list.  She  also  saw  that  the  girls 
made  up  the  fruit  mixture  and  used  it.  In  addition,  they  were 
stimulated  to  take  plenty  of  exercise  outside  of  working  hours.  With- 
in one  month  the  constipation  was  completely  overcome  in  every  case, 
and  within  three  months  the  ten  girls  who  had  been  accustomed  to 
report  to  the  rest  room  for  their  sick  time  or  to  remain  away  from 
their  work  for  a  day,  ceased  this  practice. 

Proper  diet,  sufficient  exercise  and  considerable  educational 
propaganda  a  ainst  the  habit  of  taking  cathartics  will  decrease 
the  amount  of  constipation  among  all  employees  to  a  marked  extent. 
Such  efforts  are  of  the  greatest  economic  value  to  the  industry. 

Dysmenorrhea. — Among  concerns  employing  great  numbers  of 
girls,  this  condition  of  painful  menstruation  causes  an  incalculable 
loss  of  time  from  work  and  decreased  efficiency  before  and  after  as 
well  as  during  the  periods. 

The  causes  of  this  condition  are  many.  A  small  percentage  are 
due  to  anatomical  displacements  or  some  pathological  change  in  the 
generative  organs.  The  majority  of  the  cases,  however,  are  traceable 
to  other  conditions  more  or  less  remote  from  the  pelvis.  Of  these,  con- 
stipation, and  the  conditions  predisposing  to  this,  such  as  improper 
food,  lack  of  exercise,  etc.,  is  the  commonest  cause.  A  few  years  ago, 
many  state  legislatures  endeavored  to  improve  health  conditions 
among  working  girls  by  enacting  laws  making  it  necessary  for  them  to 
sit  while  at  work.     In  my  opinion  constant  sitting  during  the  long 


WOMEN    IN    INDUSTRY  427 

working  hours  is  as  bad,  if  not  worse,  than  constant  standing.  This 
sitting  posture  causes  more  or  less  congestion  of  the  pelvic  organs 
which  is  increased  by  constipation  so  often  associated  with  constant 
sitting.  If  girls  could  be  persuaded  to  dress  properly  and  then  could 
be  gradually  trained  to  standing  and  walking  for  several  hours,  much 
healthier  employment  could  be  found  for  them  than  the  sedentary 
occupations  to  which  they  are  now  condemned,  chiefly  by  legislature. 
Under  the  existing  conditions,  occupations  which  allow  part  time 
sitting  and  part  time  standing,  or  if  this  is  impossible,  frequent  rest 
periods  which  will  allow  the  girls  to  stand  and  move  about,  will  be 
found  of  the  greatest  benefit  in  overcoming  dysmenorrhea. 

The  next  commonest  cause  for  this  condition  can  be  found  in  an 
unstable,  nervous  mechanism.  A  large  percentage  of  the  girls  who 
reported  to  the  doctor's  office  because  of  painful  menstrual  periods 
also  reported  at  other  times  because  of  various  nervous  manifestations, 
such  as  fainting,  hysteria,  "nervousness"  and  many  neurasthenic 
symptoms.  I  have  submitted  hundreds  of  these  girls  to  thorough 
physical  examinations  (not  including  vaginal)  and  many  of  these 
have  shown  the  signs  of  neurocirculatory  asthenia,  the  long  narrow 
chest  with  the  acute  intercostal  angle  (Stiller  type),  movable  or 
even  floating  kidneys  especially  of  the  right  side,  and  exaggerated 
abdominal  reflexes.  These  cases  are  so  common  that  the  nurse  who 
was  present  at  the  time  of  examinations  voluntarily  remarked  about 
the  similarity  of  the  findings.  Many  girls  suffer  from  neurasthenic 
symptoms  during  their  periods  which  are  based  upon  the  teaching 
or  on  the  lack  of  teaching  of  the  mother.  Instead  of  being  told  of  this 
normal  condition  in  their  sex,  they  are  suddenly  frightened  to  death  by 
its  appearance.  They  are  then  told  to  keep  quiet,  avoid  excitement, 
never  bathe  and  similar  instructions  all  of  which  stimulates  fear  of 
consequences  and  tends  to  develop  the  neurasthenic  state  at  each 
subsequent  period.  It  is  imperative  that  our  girls  be  taught  that  this 
is  a  normal  condition  and  should  not  be  regarded  as  a  ''sick  time," 

I  have  submitted  girls  to  vaginal  and  rectal  examinations,  usually 
under  gas  anesthesia,  whose  dysmenorrhea  could  not  be  accounted 
for  by  the  above  conditions  or  cured  by  the  correction  of  the  same. 
Only  about  10  per  cent,  of  these  oases  showed  definite  pathologic 
changes  which  could  account  for  the  dysmenorrhea.  Of  these,  an 
acute  retroflexion  of  the  uterus  was  the  commonest  finding,  marked 
retroversion  being  the  next  commonest  condition.  In  many  of  these 
cases  the  rectum  was  found  impacted  with  fecal  matter  even  when 
constipation  was  not  complained  of.  Care  of  the  bowels  and  proper 
exercises,  such  as  assuming  the  knee  chest  position  for  several  minutes, 
three  times  a  day,  relieved  many  of  these  while  in  a  few  an  opera- 
tion was  necessary.     The  operative  cases  gave  uniformly  good  results 


428  INDUSTRIAL    MEDICINE    AND    SURGERY 

chiefly  because  such  radical  treatment  was  not  instituted  until  all 
other  sources  of  the  trouble  had  been  eliminated  except,  perhaps, 
some  due  to  neurasthenia. 

The  number  of  girls  suffering  from  dysmenorrhea  in  the  working 
force  can  be  greatly  reduced  by  systematic  efforts  directed  toward  this 
end  by  the  medical  staff.  Here  the  nurse  and  intelligent  foreladies 
can  be  of  greatest  assistance,  in  fact  they  must  often  take  the  lead  in 
directing  the  routine  measures  suggested  by  the  doctor.  The  first 
essential  is  to  decrease  the  number  of  cases  of  constipation  to  a 
minimum.  Directions  for  this  are  given  above.  Next,  every  in- 
dustry employing  girls  should  provide  the  means  for  healthful  recrea- 
tion including  games  which  afford  plenty  of  outdoor  exercise.  Lectures 
will  be  found  of  great  value,  but  better  than  this  is  a  careful  study  of 
each  case  of  dysmenorrhea  followed  by  individual  instructions  con- 
cerning the  methods  of  overcoming  it.  The  nurses  can  give  these 
instructions  by  many  intimate  talks  with  the  girls.  Hot  drinks, 
especially  those  containing  certain  food  values,  combined  with  a  short 
rest  in  the  rest  room,  will  enable  many  to  return  shortly  to  work 
whereas  medicine  given  to  relieve  the  pain  only  tends  to  create  a 
habit. 

This  short  resume  concerning  this,  one  of  the  most  important 
problems  in  industry,  is  given  with  a  view  of  stimulating  more  con- 
certed action  on  the  part  of  both  physicians  and  nurses  in  industry 
in  order  to  overcome  a  condition  which  has  hitherto  been  tolerated. 
In  correcting  dysmenorrhea,  many  of  the  faulty  conditions  surrounding 
women  in  industry  will  likewise  be  corrected. 


CHAPTER  XXIX  / 

THE  TUBERCULOUS  EMPLOYEE 

Tuberculosis  has  been  a  greater  enemy  of  the  human  race  than 
almost  any  other  disease.  Its  devastation  has  surpassed  the  wanton 
destruction  of  savages. 

The  pulmonary  type  is  the  commonest  form  of  tuberculosis,  but 
it  also  involves  glands,  bones  and  joints,  the  serous  linings  of  cavities, 
as  the  pleura,  peritoneum,  and  meninges,  and  attacks  other  organs 
of  the  body  as  the  kidney  or  the  testicle. 

In  dealing  with  the  problem  of  the  tuberculous  employee  the 
pulmonary  type  only  will  be  considered,  but  the  principles  herein 
set  forth  are  applicable  to  practically  all  forms  of  this  disease. 

Tuberculosis  is  not  a  disease  of  industrial  life  alone.  It  existed 
even  more  extensively  among  the  American  Indians  and  other 
aborigines,  where  our  modern  industrial  conditions  were  unknown. 
The  more  favored  in  life,  from  the  standpoint  of  wealth  and  social 
position,  have  succumbed  to  its  ravages.  Among  the  agricultural 
class,  where  outdoor  life  and  abundance  of  food  prevail,  the  disease 
has  been  very  common.  But  unquestionably  it  has  caused  the 
greatest  destruction  among  the  poor  working  classes  in  our  industrial 
centers. 

In  all  nations  as  the  tendency  to  concentrate  in  certain  communities 
increased,  and  as  small  shops  grew  into  factories,  and  these  into  great 
congested  industries,  the  working  people  were  more  and  more  crowded 
together.  Small  homes  were  replaced  with  flats  and  these  in  turn 
with  large  tenement  buildings.  Not  only  were  the  working  places 
overcrowded  and  unhygienic,  but  the  families  of  these  workers  were 
forced  to  live  in  congested  quarters,  ill-ventilated,  unclean  and  in- 
sanitary to  the  extreme. 

Tuberculosis  has  reached  its  highest  morbidity  and  mortality  rate 
among  these  poor  working  classes.  They  become  centers  of  infection 
and  spread  the  disease  to  all  other  walks  of  life,  even  reaching  the 
homes  of  the  landlords  who  are  responsible  for  such  community 
conditions. 

This  disease  has  become  so  prevalent  that  autopsy  statistics  show 
that  from  70  per  cent,  to  85  per  cent,  of  all  people  have  at  some  time 
during  their  life  been  infected.  Healed  or  inactive  areas  of  the  disease 
have  been  found  in  a  large  percentage  of  those  dying  from  some  other 

429 


430  INDUSTRIAL    MEDICINE    AND    SURGERY 

cause.  It  is  hard  to  explain  why  more  do  not  succumb  to  tuber- 
culosis but  undoubtedly  the  fact  that  our  working  and  living  condi- 
tions do  not  tend  to  lower  our  resistance  is  the  saving  factor  for  many. 

Some  of  our  modern  tuberculosis  specialists  contend  that  this 
disease  is  not  infectious  to  adults.  They  argue  that  the  focus  of 
infection  is  contracted  during  childhood  and  in  later  life  some  under- 
mining condition  so  lowers  the  resistance  as  to  cause  the  disease  to 
light  up.  These  teachers  have  caused  some  to  doubt  if  it  is  necessary 
to  protect  the  working  forces  from  the  tuberculous  employee  in 
their  midst.  They  even  argue  that  the  husband  sleeping  with  the 
tuberculous  wife  cannot  contract  the  disease  from  her.  There  is 
abundance  of  proof  of  this  infection  of  children  but  this  fact  does  not 
refute  the  arguments  that  overcrowding,  unsanitary  living  and  work- 
ing conditions  and  even  certain  occupations  are  equally  responsible 
for  the  spread  of  tuberculosis. 

Therefore  while  tuberculosis  may  be  classed  as  an  industrial  disease 
yet  many  conditions  in  industry  have  been  responsible  for  maintaining 
and  spreading  it.  Granting  that  the  infection  is  one  of  childhood  yet 
certain  occupations  and  certain  insanitary  industrial  conditions  are 
responsible  for  the  lowered  resistance  and  the  lighting  up  of  the  in- 
fection. Even  if  the  presence  of  the  tuberculous  employee  is  not 
dangerous  to  his  fellows  yet  these  same  working  conditions  can  in- 
crease the  activity  and  dangers  of  the  disease  for  him  and  therefore 
this  fact  makes  it  imperative  to  remove  him  from  the  working  place 
until  he  has  recovered. 

The  irrefutable  proof  of  these  statements  exists  in  the  fact  that  in 
those  industries  where  an  active  fight  against  this  disease  has  been 
made  the  tuberculosis  rate  has  rapidly  decreased.  With  improved 
living  conditions  and  plant  sanitation,  even  though  not  directed  espe- 
cially at  the  prevention  of  tuberculosis,  the  disease  has  decreased.  In 
those  occupations,  which  have  been  directly  responsible  for  lung 
trouble  even  crude  preventive  measures  have  decreased  phthisis  to  a 
remarkable  extent.  And  the  seeking  out  of  the  tuberculous  employee 
and  removing  him  from  the  presence  of  his  fellows,  placing  him  under 
proper  conditions  for  recovery,  have  resulted  in  decreasing  both 
the  morbidity  and  mortality  rate. 

The  extent  to  which  tuberculosis  may  be  classed  as  an  industrial 
disease  may  be  disputed,  but  no  argument  can  exist  against  the  fact 
that  improving  industrial  conditions  decreases  the  tuberculosis  rate. 
But  the  employer  alone  cannot  be  blamed  for  these  deplorable  con- 
ditions which  make  the  disease  so  prevalent.  Society  at  large  is 
responsible  to  a  certain  extent.  And  society,  through  the  official 
agencies  of  the  state  and  federal  governments,  should  improve  all 
conditions  tending  to  lower  the  nation's  resistance  and  should  in 


THE  TUBERCULOUS  EMPLOYEE  431 

addition  provide  the  machinery  for  discovering  and  properly  curing 
the  tuberculous  people  among  us.  A  concerted  fight  on  the  part  of 
the  nation  against  this  disease  would  in  time  eradicate  it  completely 
and  at  the  same  time  would  solve  most  of  the  social  evils  coincidental 
with  it. 

The  tuberculous,  whether  he  is  the  single  employee  of  a  small 
shop  or  one  of  a  hundred  thousand  working  force  in  an  industry, 
must  be  sought  out  and  cared  for.  The  conditions  in  his  working 
place  or  in  his  home  that  made  the  disease  possible  must  be  removed. 
All  who  come  in  intimate  contact  with  him  must  be  examined  for 
possible  infection.  In  fact  each  individual  case  must  be  thoroughly 
studied  and  the  possibilities  of  the  spread  of  the  disease  from  this 
source  must  be  followed  out  in  all  its  ramifications.  Such  a  machinery 
will  not  only  reach  the  tuberculous  in  adult  life  but  will  reach  into 
childhood  as  well. 

Under  the  incentive  of  war  we  have  seen  the  nations  mobilize 
their  forces  and  concentrate  their  every  effort  against  the  common 
enemy  which  was  spreading  death  and  degradation  among  us.  The 
medical  forces,  sacrificing  personal  wealth  and  aggrandizement,  have 
responded  gloriously  in  this  fight.  If  we  could  maintain  this  same 
great  war  machine,  and  the  civilian  agencies,  such  as  the  Red  Cross 
and  all  government  agencies,  after  the  war,  to  concentrate  their  efforts 
against  tuberculosis,  and  all  the  other  social  diseases,  devastaling  our 
people  even  more  than  war  has  done,  it  would  result  in  a  more  glorious, 
far  reaching  victory  than  we  are  gaining  over  the  Huns. 

PREVALENCE  OF  TUBERCULOSIS  IN  INDUSTRY 

It  is  not  our  purpose  to  classify  all  tuberculous  employees  as  the 
victims  of  an  occupational  disease  and  thereby  add  to  the  liability  of 
the  employer  in  these  cases.  But  rather  to  show  that  in  some  cases 
there  is  a  legal  responsibility  and  in  many  others  a  moral  responsibility 
which  must  be  assumed  by  the  employer  at  this  time  in  the  absence 
of  any  state  responsibility  for  these  sufferers.  And  the  physician  in 
industry  is  in  the  strategical  position  to  attack  this  disease  where  it  is 
the  most  prevalent. 

The  causes  of  tuberculosis  in  industry  can  be  divided  into  pre- 
disposing etiologic  factors,  the  active  cause  being  the  bacillus  of 
tuberculosis  itself,  discovered  by  Koch  in  1880.  The  relationship 
to  industry  of  some  of  these  predisposing  conditions  is  very  remote, 
while  others  are  so  closely  connected  with  certain  industries  that  they 
represent  almost  an  active  causal  agency.  In  the  latter  cases  tuber- 
culosis should  be  classed  as  an  occupational  disease,  the  emploj^er 
being  held  liable  for  the  condition.     Only  in  this  way  will  the  proper 


432  INDUSTRIAL    MEDICINE    AND    SURGERY 

preventive  measures  be  taken  where  these  more  or  less  active  causes 
exist. 

These  predisposing  factors  to  tuberculosis  among  employees  are  as 
follows : 

1.  Hereditary  predisposition  and  family  infection. 

2.  Poor  housing  and  living  conditions  and  other  community 
conditions. 

3.  Alcoholism  and  other  excesses.. 

4.  Unsanitary  working  places  and  working  conditions. 

5.  Tuberculous  employees  among  the  working  force  forming  "foci 
of  infection." 

6.  Prevalence  of  other  diseases. 

7.  Injuries  to  chest  and  other  injuries. 

8.  Specific  occupational  hazards. 

The  relationship  of  industry  to  hereditary  predisposition  and 
to  family  infection  is  indeed  very  remote  and  yet  it  exists.  In  cer- 
tain industries,  as  for  instance  the  textile  workers  of  New  England, 
or  in  the  copper  mines  of  Montana,  the  children  often  follow  the  parents 
into  the  mills  or  mines.  Physicians  in  these  communities  have  told 
me  of  members  of  families,  for  at  least  three  generations,  dying  of 
this  disease.  Heredity  and  family  infection  have  undoubtedly  played 
their  part  but  the  working  conditions  have  been  responsible  to  a  cer- 
tain extent  for  these  deaths.  In  some  of  these  families  where  each 
succeeding  generation  has  followed  the  occupation  of  the  parents 
the  signs  of  a  hereditary  predisposition  to  tuberculosis  have  in- 
creased in  each  group  of  children.  The  smaller  stature,  the  narrow 
chest  and  the  stooped  shoulders  of  these  children  point  to  industries' 
responsibility  toward  them  and  toward  society.  Improved  working 
conditions,  with  every  preventive  measure  installed,  would  stop  these 
family  infections. 

Poor  housing  and  living  conditions  increase  the  number  of  tuber- 
culous employees.  Some  industries  have  even  provided  long  rows 
of  tenements  for  their  employees  and  their  families.  These  poorly 
built  homes,  with  their  insanitary  arrangements,  and  their  dark,  ill- 
ventUated  sleeping  rooms,  have  reduced  the  efficiency  of  their  workers 
and  caused  disease  to  become  more  prevalent.  Poverty  among  em- 
ployees has  forced  them  to  dwell  in  unhygienic  surroundings  and  to 
live  under  conditions  which  have  been  proven  by  many  investigators 
to  predispose  to  tuberculosis. 

The  employer  should  see  that  the  community,  responsible  for  fur- 
nishing him  his  labor  supply,  is  cleaned  up  and  kept  clean;  that  his 
employees  are  paid  a  living  wage  and  are  subtly  educated  to  proper 
living  environments.  All  his  efforts  to  improve  health  conditions 
in  his  plant  can  be  undone  by  unhealthful  community  conditions. 


THE  TUBERCULOUS  EMPLOYEE  433 

Good  business,  as  well  as  a  certain  moral  responsibility,  should  force 
every  concern  to  remove  these  predisposing  causes. 

Alcoholism,  venereal  diseases  and  many  other  forms  of  excesses, 
are  acknowledged  predisposing  factors  to  tuberculosis,  as  well  as 
a  direct  cause  of  inefficiency.  Beer  drinking  during  working  hours 
has  increased  at  an  alarming  rate  among  the  workers  of  hundreds  of 
different  industries.  Some  of  these  employees  will  drink  at  least  two 
gallons  of  beer  during  the  day.  This  is  encouraged  by  some  employers, 
and  not  prohibited  by  others  for  the  fear  of  losing  these  men.  Other 
concerns  have  increased  alcoholism  by  paying  in  checks  and  allowing 
the  corner  saloon  to  cash  these  checks.  In  many  communities  the 
saloon  offers  the  only  club  facilities  for  the  working  class.  They  can 
go  here  and  eat  their  lunches  in  warmth,  and  in  the  evening  can  find 
a  warm  place  to  congregate  where  facilities  for  games  and  amusements 
are  freely  furnished.  In  such  communities  the  cheap  dance  hall  is  the 
only  source  of  entertainment  for  the  girls.  Alcoholism,  venereal  dis- 
eases and  late  hours  prevail,  and  result  in  tuberculosis  and  inefficiency. 
Society  and  the  industries  that  do  not  provide  the  means  of  combat- 
ing these  conditions  are  responsible.  Dr.  Wilbur  Post  recognized 
the  deleterious  effects  of  alcoholism  on  the  employees  of  a  large  industry 
in  Chicago.  These  men  were  in  the  habit  of  "rushing  the  growler" 
during  working  hours,  and  to  have  their  beer  at  the  noon  hour  with 
whiskey  in  the  morning  and  evening.  He  arranged  through  the 
management,  to  meet  small  groups  of  employees  each  day  for  a  twenty 
minute  talk,  on  the  company's  time.  He  gave  these  talks  until  every 
man  in  the  concern  had  heard  them  several  times.  In  a  snappy, 
subtle  way  he  drove  home  the  undermining  influences  of  this  constant 
use  of  alcohol,  and  in  time  decreased  the  sale  of  beer  among  these 
men  over  75  per  cent.  Buttermilk  was  advocated  as  a  substitute 
and  the  concern  saw  that  opportunity  for  buying  buttermilk  was 
provided. 

The  environments  of  the  working  place  are  frequently  the  cause 
of  tuberculosis,  and  here  the  industry  is  more  directly  responsible  for 
the  disease.  Overcrowding  of  working  places  was  best  exemplified  by 
the  sweat-shops  among  garment  workers  so  prevalent  a  few  years  ago. 
Doctors  Price  and  Scherechewsky  found  in  2000  garment  workers 
in  New  York  a  tuberculosis  rate  of  5  per  cent.,  whereas  among  1000 
steel  workers  they  only  found  .9  per  cent,  affected  with  this  disease. 

Poor  ventilation  usually  is  coincident  with  overcrowding.  Vitality 
is  practically  always  reduced  by  ill  ventilated,  contaminated  working 
rooms.  The  presence  of  inorganic  dust  and  of  pathogenic  bacteria 
thrown  off  from  the  workers  in  the  room  add  greatly  to  the  disease 
hazard. 

Lack  of  facilities  for  the  proper  removal  of  dust  is  another  hazard 

28 


434  INDUSTRIAL    MEDICINE    AND    SURGERY 

for  tuberculosis.  Dry  sweeping  in  the  rooms,  where  people  are 
employed  is  one  of  the  most  dangerous  practices.  Dust  created  in  many 
occupational  processes  is  known  to  be  especially  predisposing  to 
respiratory  conditions.  Ventilators,  fans  and  artificial  means  of  remov- 
ing dusts  are  imperative;  where  such  appliances  are  neglected  there 
is  a  direct  responsibility  on  the  employer  for  the  cases  of  tubercu- 
losis which  develop. 

Forcing  employees  to  work  constantly  in  dark,  damp  places 
is  a  cause  for  lowered  vitality  and  a  predisposition  to  tuberculosis. 
That  such  working  places  cannot  be  avoided  at  times  may  be  granted, 
but  no  man  should  be  forced  to  work  there  day  in  and  day  out.  These 
employees  should  be  changed  frequently,  say  every  three  weeks, 
to  outside  employment.  They  should  also  be  subjected  to  more 
frequent  physical  examinations  and  other  forms  of  health  supervision 
to  prevent  the  incipient  development  of  this  disease. 

Exposure  to  extremes  of  heat  and  cold,  and  other  forms  of  poor 
temperature  and  humidity  provisions,  is  another  predisposing  factor 
in  industry  which  is  responsible  for  many  cases  of  phthisis. 

Industrial  sanitation  is  the  means  of  removing  all  these  factors 
and  that  industry  which  neglects  the  environments  of  its  working 
force  should  be  held  liable  for  its  tuberculous  employee. 

Employees  working  in  intimate  contact  with  each  other,  are 
constantly  exposed  to  the  diseased  fellow  employee  in  their  midst. 
This  is  true  of  tuberculosis  as  well  as  all  contagious  diseases.  These 
men  with  tuberculosis,  where  proper  supervision  does  not  exist, 
wiU  continue  to  work  as  long  as  they  are  able,  and  meanwhile  the  dis- 
ease is  advancing  and  the  number  of  germs  thrown  off  by  their 
coughing  and  spitting  increases  daily. 

The  author  found  twenty-six  cases  of  tuberculosis  among  a 
large  nu-mber  of  packers  in  two  years.  The  sources  of  infection  were 
removed  and  in  the  next  seven  years  only  seven  cases  of  this  disease 
developed  among  this  force.  While  proper  supervision  accounted  for 
part  of  these  results,  yet  the  segregation  of  these  sources  of  infection 
undoubtedly  removed  the  cause  of  contamination. 

Ten  years  ago  when  the  physical  examination  of  employees  in 
industrial  concerns  was  first  advocated,  it  was  met  with  every  form 
of  objection.  But  today  it  is  recognized  as  one  of  the  greatest  efficiency 
measures,  as  well  as  the  most  advanced  public  health  movement, 
which  can  be  adopted.  It  is  the  greatest  means  of  health  supervision, 
and  health  supervision  of  employees  forms  the  very  foundation  of  all 
common-sense  efforts  at  so  called  welfare  work.  Every  employer 
should  see  that  his  working  force  is  carefully  supervised  in  order  to 
discover  and  remove  these  foci  of  infection^ — -the  tuberculous 
employees. 


THE  TUBERCULOUS  EMPLOYEE  435 

Certain  industries,  due  either  to  unsanitary  conditions,  or  the  nature 
of  the  work,  or  the  location  of  the  plant,  seem  predisposed  to  other 
respiratory  diseases  These  diseases  are  often  the  cause  of  the  lighting 
up  of  a  case  of  tuberculosis.  It  behooves  every  concern,  therefore  to 
combat  these  antecedent  diseases.  When  the  causes  for  them  exist 
in  either  the  working  place  or  in  the  community,  every  effort  should 
be  made  to  remove  the  same  in  order  to  prevent  the  worst  disease — 
tuberculosis. 

Following  the  epidemic  of  so  called  grip,  in  the  winter  of  1915,  the 
author  found  eighteen  cases  of  tuberculosis  in  the  month  of  March 
among  employees  who  had  been  working  in  a  concern  where  careful 
medical  supervision  was  in  vogue.  Twelve  of  these  employees  had 
been  thoroughly  examined  during  the  preceding  year,  and  no  evidence 
of  tuberculosis  was  found.  This  epidemic  was  responsible  for  light- 
ing up  tiie  disease.  Our  efforts,  which  resulted  in  controlling 
the  "grip"  epidemic,  and  in  reducing  the  sick  rate  among  these 
employees  to  a  much  lower  percentage  than  that  in  the  community 
at  large,  undoubtedly  reduced  the  number  of  tuberculosis  cases 
which  followed  in  its  wake.  Overcrowding,  poor  ventilation,  fatigue, 
and  lack  of  immediate  medical  care,  are  directly  responsible  for  the 
increasing  number  of  so  called  grippe,  or  epidemics  of  streptococcic  res- 
piratory conditions  among  employees.  These  epidemics  are  becoming 
more  and  more  a  cause  of  immediate  high  absence  rate  among 
employees.  The  extent  to  which  they  are  contributing  to  absenteeism 
in  the  following  months,  chiefly  because  of  tuberculosis  cannot  be 
estimated. 

Cigar  makers  are  more  subject  to  these  milder  respiratory 
conditions,  and  they  are  also  known  to  have  a  higher  tuberculosis  rate 
than  many  other  employees.  Protection  against  these  milder  condi- 
tions would  result  in  a  lowered  tuberculosis  morbidity. 

These  two  examples  are  sufficient  to  point  out  the  responsi- 
bility of  the  employer  in  protecting  his  working  force  from  those 
influences  which  cause  these  antecedent  diseases  which  often  result  in 
consumption. 

Sir  Thomas  Oliver,  in  his  book  on  Diseases  of  Occupation,  has  devoted 
considerable  attention  to  the  relationship  between  traumatism  and 
tuberculosis.  He  describes  several  cases  of  injury  to  the  chest  in 
men  who  later  developed  tuberculosis.  Some  of  these  had  been 
examined  previous  to  the  injury  and  no  sign  of  tuberculosis  was  dis- 
covered, neither  was  there  any  family  tendency  to  this  disease.  One 
case,  a  previously  healthy  male,  two  weeks  after  a  severe  blow  on  his 
chest,  developed  a  pleurisy.  This  man  continued  to  lose  weight  and 
grew  rapidly  worse.  A  few  weeks  later  his  physician  found  tubercle 
bacilli  in   his   sputum.     Under   proper   treatment   the   man   finally 


436  INDUSTRIAL    MEDICINE    AND    SURGERY 

recovered.     The  conclusion  was  reached  that  the  trauma  was  responsible 
for  the  disease. 

In  my  experience,  I  have  had  twelve  cases  of  traumatic  pleurisy. 
All  of  these  followed  a  direct  injury  to  the  chest  wall;  none  had  evidence 
of  fractured  ribs.  One  of  these  developed  the  signs  and  symptoms 
of  tuberculosis,  but  the  germs  were  never  found  in  his  sputum.  After 
three  months  of  treatment  which  corresponded  in  every  respect  with 
the  treatment  of  tuberculosis,  the  man  recovered.  At  the  time  of 
the  injury  a  stethoscopic  examination  of  his  chest  revealed  none 
of  the  signs  which  later  developed.  This  stethoscopic  examina- 
tion of  every  injury  to  the  chest  wall  is  very  important,  and  will 
often  enable  the  physician  to  prevent  an  injustice  being  done  to  either 
the  employer  or  employee. 

One  of  the  above  cases  was  struck  in  the  lower  side  of  his  left  chest 
by  a  falling  box.  He  reported  to  the  doctor's  ofl&ce  at  once.  The 
routine  examination  with  the  stethoscope  was  made  and  signs  of  tuber- 
culosis were  found  in  both  apices.  His  sputum  was  immediately 
examined  and  found  to  contain  the  germs.  An  a;-ray  examination 
showed  no  fractured  ribs,  but  revealed  large  areas  of  calcification  and 
fibrosis  in  the  lungs.  The  condition  was  explained  to  the  boy  and 
his  family.  It  was  carefully  pointed  out  that  this  disease  was  already 
existent  and  active  and  that  the  blow  had  nothing  to  do  with  it.  This 
concern  followed  its  usual  custom  and  sent  this  employee  to  a  sana- 
torium for  treatment,  paying  all  of  his  expenses.  He  recovered  and 
left  the  sanatorium  in  seven  months  and  was  again  employed.  The 
injury  to  his  chest  wall  did  not  seem  to  increase  his  lung  trouble.  A 
case  similar  to  this  is  described  under  the  medicolegal  chapter. 

Another  employee  received  a  nail  wound  of  the  hand  and  developed 
a  severe  streptococcus  infection.  At  his  first  general  examination, 
made  one  week  after  the  injury,  no  signs  of  tuberculosis  were  found. 
There  was  no  family  history  of  this  disease.  The  infection  in  the 
hand  persisted  for  several  weeks  and  required  extensive  drainage  under 
a  general  anesthetic.  He  finally  recovered  from  this,  but  remained 
emaciated  and  did  not  regain  his  strength.  About  three  months 
after  the  injury  he  began  to  cough  and  expectorate.  Dullness  and 
rales  developed  in  the  lungs  and  tubercle  bacilli  were  found  in  the 
sputum.  My  opinion  was  demanded  as  to  whether  the  injury  was 
responsible  for  this  pulmonary  condition.  The  fact  that  there  was 
no  evidence  of  the  disease  one  week  after  injury,  and  that  his  lowered 
resistance  followed  directly  as  the  result  of  the  severe  infection,  making 
it  possible  for  this  disease  to  develop,  caused  me  to  give  the  opinion 
that  his  injury  was  the  predisposing  factor,  and  the  employer  should 
be  responsible. 

There  is  no  doubt  but  that  injuries  can  predispose  to  tuberculosis, 


THE  TUBERCULOUS  EMPLOYEE  437 

* 

and  it  is  essential  for  industry  to  recognize  the  fact  and  take  the  neces- 
sary precautions  against  accidents,  and  provide  the  best  of  care  for  all 
injured  in  order  to  prevent  this  complication. 

OCCUPATIONAL  HAZARDS 

Tuberculosis  follows  so  frequently  in  the  wake  of  certain  occupa- 
tions that  these  have  come  to  be  recognized  as  definite  predisposing 
causes  for  the  disease.  Just  as  plumbism  is  a  definite  occupational 
disease  for  which  employers  may  be  held  legally  liable,  so  tubercu- 
losis should  be  classed  as  an  occupational  disease  when  it  develops  in 
certain  industries. 

Frederick  S.  Crum  in  his  treatise  on  "The  Mortality  from  Diseases 
of  the  Lungs  in  American  Industry,"  Hoffman  and  other  excellent, 
authorities,  have  definitely  demonstrated  that  certain  occupations  are 
directly  responsible  for  this  pulmonary  condition. 

Those  industrial  processes  which  contaminate  the  atmosphere  of  the 
working  place  with  inorganic  or  organic  dusts  are  especially  pre- 
disposing to  pulmonary  tuberculosis,  as  well  as  to  other  respiratory 
diseases.  It  is  estimated  that  approximately  5,500,000  wage  earners 
of  both  sexes,  or  12.5  per  cent,  of  the  total  wage  earning  force  of 
the  country  work  under  conditions  where  this  atmospheric  pollution  is 
very  prevalent,  and  of  known  hazard  to  the  employees.  A  careful 
investigation  in  many  of  the  smaller  concerns,  and  of  the  more  ob- 
scure occupations,  would  undoubtedly  reveal  a  higher  percentage  of 
workers  exposed  to  dust  hazards. 

The  metallic  dusts,  with  their  millions  of  jagged,  angular  micro- 
scopic particles  floating  in  the  atmosphere,  are  probably  the  most 
hurtful  to  the  lung  tissue.  The  constant  irritation  from  these  particles 
causes  a  fibrosis  which  is  a  favorable  garden  spot  for  the  tubercle 
bacillus,  or  may  cause  death  from  some  other  respiratory  disease. 

Mr.  Crum  based  his  study  on  the  experience  of  the  Prudential 
Life  Insurance  Company  which  for  years  has  kept  careful  statistics 
on  the  causes  of  death  among  policy  holders  engaged  in  these  dusty 
occupations.  He  says,  "In  the  Prudential  experience  the  group  of 
occupations  exposing  the  workmen  to  metallic  dust  shows  the  most 
disastrous  results,  as  evidenced  in  the  mortality  returns  from  both 
tuberculosis  of  the  lungs  and  other  respiratory  diseases.  At  ages 
25  to  34,  taking  the  group  as  a  whole,  of  the  total  deaths  53.9  per  cent, 
were  caused  by  tuberculosis  of  the  lungs  and  8  per  cent,  were  from 
other  respiratory  diseases.  Respiratory  diseases  at  this  age  period 
together  caused  an  excess  mortality  of  25.3  per  cent,  if  comparison 
is  made  with  the  mortality  from  these  diseases  in  the  non-dusty  oc- 
cupations.    At  ages  35  to  44,  tuberculosis  of  the  lungs  caused  44.7 


438  INDUSTRIAL   MEDICINE    AND    SURGERY 

per  cent,  of  the  total  deaths  and  the  other  respiratory  diseases  caused 
9.7  per  cent.  In  other  words,  respiratory  diseases,  tuberculous  and 
non-tuberculous,  caused  54.4  per  cent,  of  all  the  deaths  of  occupied 
males,  ages  35  to  44,  in  the  group  of  occupations  exposing  to  metallic 
dusts,  in  the  Prudential  experience.  This  represents  an  excess 
mortality  from  these  causes  of  22.2  per  cent,  as  compared  with  the 
non-dusty  occupations  in  the  same  experience. 

Specific  occupations  in  this  group  with  exceptionally  high 
mortality  from  lung  diseases  are  cutlery  makers,  file  makers,  metal 
grinders  and  polishers,  brass  workers,  printers,  engravers,  tool  makers, 
gold  beaters,  etc. 

Metal  grinders,  polishers  and  buffers  invariably  show  a  high  mor- 
tality from  respiratory  diseases  as  a  direct  result  of  their  inhalation  of 
metallic  dust  particles.  The  peculiar  effect  on  the  lungs  of  metallic 
dust  is  described  by  some  writers  on  occupational  diseases  as  ''grinders' 
rot." 

In  the  Prudential  experience,  metal  grinders  and  polishers  show 
an  excess  mortality  from  tuberculosis  of  the  lungs  at  ages  25  to  34  of 
60  per  cent,  and  at  ages  35  to  44  an  excess  of  107.1  per  cent.  The 
mortality  of  this  class  of  workmen  from  other  diseases  of  the  lungs  was 
practically  the  same  as  ages  25  to  44  as  in  the  non-dusty  occupations. 

The  oft  quoted  figures  from  the  medical  officers  of  health  of  Shef- 
field, England,  show  that  for  the  period  of  1889  to  1910  tuberculosis 
caused  43  per  cent,  and  other  respiratory  diseases  24.9  per  cent,  of  the 
deaths  among  grinders. 

Most  mineral  dusts  cause  a  high  mortality  rate  from  tuberculosis. 
During  the  period  of  1907  to  1914  in  Montana  the  mortality  report 
among  copper  miners  shows  that  out  of  1614  deaths,  for  ages  of  15  and 
over,  611  or  37.9  per  cent,  were  due  to  tuberculosis,  and  364  or  22.6 
per  cent,  resulted  from  other  respiratory  diseases.  In  this  registra- 
tion area  the  riiale  'deaths  for  the  same  age  period  showed  14.1  per 
cent,  due  to  tuberculosis  and  10.8  per  cent,  to  other  respiratory 
causes.  These  figures  certainly  demonstrate  that  copper  mining 
is  especially  hazardous  and  results  in  excessive  mortality  from 
consumption. 

Coal  miners  and  cement  workers  seem  to  suffer  the  least  from  the 
dust  created  by  their  occupations.  In  fact  colliers  in  well  ventilated 
coal  mines  were  found  to  have  a  comparatively  low  mortality  rate 
from  this  disease  according  to  F.  A.  R.  Russel  of  the  Smithsonian 
Institute  who  wrote  on  this  subject  in  1896. 

Quoting  again  from  the  Prudential  experience  among  stone  and 
marble  cutters,-  planers  and  polishers,  we  find  these  occupations  par- 
ticularly hazardous  if  we  are  to  judge  from  their  mortality  returns. 
•The  excess  mortality  from  tuberculosis  of  the  lungs  at  ages  25  to  34 


THE  TUBERCULOUS  EMPLOYEE  439 

among  these  workmen  was  40  per  cent,  and  at  ages  35  to  44  it  was 
34.4  per  cent.  This  experience  is  confirmed  by  other  data  and  it  has 
long  been  a  well  known  fact  that  stone  cutters  are  very  liable  to  a 
fibroid  form  of  pulmonary  tuberculosis.  In  Washington  County, 
Vermont,  the  general  mortality  returns  are  available  for  the  six  year 
period,  1900  to  1905.  These  statistics  show  that  pulmonary  tuber- 
culosis caused  46.2  per  cent,  of  all  the  deaths  among  these  workers  and 
other  respiratory  diseases  caused  14.7  per  cent,  of  the  total  mortality. 
Diseases  of  the  respiratory  system,  tuberculous  and  non-tuberculous, 
were,  therefore,  responsible  for  60.9  per  cent,  of  all  the  deaths  of  stone 
and  marble  workers  in  Washington  County,  Vermont,  during  1900 
to  1905. 

Such  terms  as  "grinder's  rot, "  pneumoconiosis,  silicosis  and  others, 
prove  that  both  the  laity  and  medical  profession  have  recognized  the 
existence  of  these  conditions  among  employees  subjected  to  metal 
and  mineral  dusts. 

The  cotton  and  linen  textile  workers,  wood  workers  and  paper 
makers  are  exposed  chiefly  to  vegetable  dusts.  The  mortality  rate 
from  tuberculosis  among  these  employees  has  been  excessively  high. 
Cotton  spinners  at  ages  of  35  to  44  were  found  to  have  an  excess 
mortality  of  90  per  cent,  when  compared  with  non-dusty  occupa- 
tions for  these  ages. 

Animal  and  mixed  fiber  dust  has  also  been  found  very  injurious 
to  the  lungs.  For  example,  among  hat-makers  the  mortality  rate  from 
tuberculosis  was  60  per  cent,  for  ages  25  to  34,  according  to  Mr.  Crum. 
The  death  rate  from  lung  diseases  among  leather  workers,  especially 
boot  and  shoe  employees,  has  been  notoriously  high.  In  Oxford, 
Massachusetts,  a  boot  and  shoe  factory  showed  a  record  of  one 
death  out  of  every  six  of  its  employees  due  to  tuberculosis.  Car- 
pet weavers,  upholsterers,  silk  and  woolen  mill  employees,  furriers, 
workers  in  hair  and  hair  goods,  mattress  makers,  garment  workers 
and  employees  in  many  other  occupations,  are  exposed  to  this  animal 
and  mixed  fiber  dust. 

Workers  exposed  constantly  to  street  or  municipal  dusts  were 
found  to  have  a  high  tuberculosis  mortality  rate,  judging  from  the 
Prudential  experience.  Street  car  conductors  and  street  cleaners 
were  especially  affected  by  this  form  of  dust.  This  should  be  given 
more  thought  as  many  physicians  have  been  in  the  habit  of  recom- 
mending teaming  or  the  occupation  of  chauffeur  to  the  arrested  case 
of  tuberculosis. 

The  occupations  where  general  organic  dust  was  prevalent  aU 
showed  an  increased  mortality  rate  from  tuberculosis.  For  instance, 
bakers,  candy-makers,  millers,  harness  and  shoemakers,  tanners, 
button   makers,    glove   makers,    tobacco   workers,  celluloid  workers, 


440  INDUSTRIAL    MEDICINE    AND    SURGERY 

and  grain  handlers,  showed  a  death  rate  of  51.8  per  cent,  from  this 
disease  according  to  the  Prudential  statistics. 

These  examples  of  the  occupational  hazard  of  dust  caused  Robert 
Hessler  (Dusty  Air  and  111  Health)  to  say,  "Tuberculosis  is  really  a 
protest  against  bad  air  conditions,  just  as  typhoid  is  a  protest  against 
bad  water." 

In  England,  Sir  James  Crichton  Browne  summed  up  his  experiences 
on  ''The  Dust  Problem"  as  follows:  "Industrial  dust,  'per  se,  apart 
from  poisonous  or  pestilential  mixture,  is  a  sufficiently  interesting 
theme  from  a  sanitary  point  of  view,  for  the  returns  of  mortality  re- 
veal that  notwithstanding  the  highly  successful  crusade  against  it, 
which  has  been  and  is  being  conducted  by  our  factory  inspectors,  nobly 
assisted  now  by  local  authorities,  intelligent  employers,  and  awakened 
workpeople,  it  is  still  responsible  for  an  appalling  amount  of  suffering, 
disablement  and  death. 

"The  mortality  of  the  principal  dust  producing  occupations,  com- 
pared with  that  of  agriculturists  who  live  and  work  in  what  is  prac- 
tically dustless  atmosphere,  is  excessive  to  a  startling  degree.  It  is 
not  suggested  that  this  excess  is  to  be  ascribed  to  dust  alone ;  no  doubt 
various  factors  contribute  to  it,  but  the  facts  that  it  is  due  mainly  to 
respiratory  diseases,  that  it  is  distributed  among  the  several  occupations 
pretty  much  in  proportion  to  their  dustiness,  and  that  it  has  diminished 
in  some  instances  where  dust  has  been  effectually  dealt  with,  justify 
the  conclusion  that  it  is  largely  dust-begotten." 

Many  other  occupations  have  shown  a  high  mortality  rate  from 
tuberculosis  among  the  employees.  This  field  has  only  been  scratched, 
and  it  behooves  all  physicians  in  industry  to  seek  out  those  occupations 
which  are  especially  deleterious  to  the  lungs  and  make  comprehensive 
reports  on  the  same. 

One  of  the  earliest  contributions  to  the  relationship  between 
phthisis  and  occupation  was  that  of  Perrond  in  1875.  This  writer 
drew  attention  to  the  prevalence  of  this  disease  among  the  sailors 
on  the  Rhone,  and  attributed  it  to  the  fact  that  these  men  pressed 
their  chest  wall  on  the  pole  of  the  rudder  in  steering  the  ships. 

Schereschewsky  has  repeatedly  pointed  out  that  the  cramped, 
stooping  posture  which  employees  must  assume  in  certain  occupations, 
is  responsible  for  many  of  the  lung  conditions  which  they  develop. 
For  example,  the  posture  of  the  garment  workers  has  the  effect  of 
Umiting  lung  expansion  with  a  consequent  poor  nutrition  due  to  sub- 
oxidation  and  a  resulting  lowered  resistance  to  respiratory  diseases. 
Again,  the  grinder  and  polisher  presses  the  object  he  is  working  on 
against  the  chest,  reducing  thereby  his  respiration,  and  thus  adds 
this  factor  to  the  hazard  of  dust. 

Dr.  James  Britton  of  Chicago  found  a  much  higher  rate  of  tuber- 


THE    TUBERCULOUS    EMPLOYEE  441 

culosis  among  the  1000  clerks  of  a  large  industry  located  in  the  city 
than  among  the  factory  employees  working  at  the  outskirts  of  the 
city.  The  former  had  far  better  environments  in  their  working  places 
than  the  latter.  But  the  sedentary  work  and  the  posture  assumed 
when  sitting  at  the  desk  evidently  lowered  the  resistajice  of  these 
clerks. 

The  author's  experience  was  quite  similar  to  that  of  Doctor  Britton. 
In  300  cases  of  tuberculosis  among  employees  of  a  large  industry 
31  per  cent,  were  among  the  clerical  force,  which  constituted  about 
30  per  cent,  of  the  entire  force.  Packers  and  allied  workers  made  up 
about  10  per  cent,  of  the  force,  and  furnished  13  per  cent,  of  the  cases 
of  phthisis;  approximately  3  per  cent,  of  the  employees  were  truckers 
and  6  per  cent,  of  the  cases  were  found  among  these.  Their  work, 
as  a  rule,  subjected  them  to  considerable  exposure  to  dust.  A  com- 
paratively small  force  of  porters  were  employed,  yet  3  per  cent,  of 
the  tuberculosis  cases  came  from  this  group.  This  bears  out  ^he 
experience  of  other  authorities  that  porter  work  is  particularly 
hazardous  as  regards  phthisis.  Better  measures  must  be  adopted  for 
sweeping  and  the  handling  of  cuspidors  and  other  refuse  in  order  to 
protect  these  porters  against  infection. 

Among  the  clerical  workers  the  stenographers  showed  a  greater 
tendency  to  the  disease.  No  better  argument  can  be  advanced  for 
rest  periods  with  exercise,  especially  deep  breathing  exercises,  and  for 
educational  campaigns  on  the  need  of  proper  recreation  at  the  noon 
hour  and  in  the  evening,  for  these  stenographers  and  other  sedentary 
workers  in  industry. 

Old  paper  gathered  up  in  the  various  departments  and  old  paper 
bought  up  from  rag  pickers  is  put  through  paper  cutting  machines 
and  used  by  many  concerns  for  packing  purposes.  The  dust  from 
this  paper  is  undoubtedly  contaminated  with  pathogenic  organisms 
to  a  marked  degree.  Straw  used  in  packing  is  also  very  dusty.  These 
materials  add  greatly  to  the  hazard  of  this  occupation.  When  this 
fact  was  pointed  out  to  one  large  concern  they  immediately  built 
a  factory  in  Northern  Michigan  and  made  excelsior  to  be  used  for 
packing  purposes.  This  clean  material,  with  its  decreased  dust,  plus 
the  fact  that  the  sources  of  infection  were  removed,  by  discovering 
and  eliminating  all  tuberculous  employees  in  their  working  force, 
has  been  the  means  of  reducing  phthisis  among  their  packers. 

These  examples  of  the  tendency  of  certain  work  to  predispose  to 
tuberculosis  are  sufficient  to  prove  that  the  employer  who  fails  to  take 
proper  precautionary  measures  to  prevent  this  disease  among  his 
employees,  engaged  in  these  hazardous  occupations,  should  be  held 
responsible  for  this  the  same  as  for  any  other  occupational  disease. 


442  INDUSTRIAL    MEDICINE    AND    SURGERY 

PREVENTION 

What  measures  therefore  are  necessary  to  prevent  tuberculosis 
among  employees? 

They  are  (a)  eliminate  the  tuberculous  from  the  working  force ;  (6) 
protect  the  employees  from  the  predisposing  causes ;  (c)  supervise 
the  physical  condition  of  the  workers  by  medical  examinations. 

The  examination  of  all  applicants  for  work  furnishes  the  only 
means  of  preventing  these  foci  of  infection,  the  tuberculous,  from 
mingling  with  the  old  working  force.  Likewise,  the  constant  super- 
vision of  the  health  of  the  old  employees  by  medical  examinations 
will  reveal  those  who  have  developed  this  disease  and  who  must  also 
be  eliminated  from  the  working  place.  There  is  sufficient  evidence 
of  the  spread  of  tuberculosis  from  one  individual  to  another  by  close 
daily  contact,  especially  when  predisposing  conditions  in  the  work 
lower  the  resistance  of  the  employees,  to  warrant  the  segregation 
and  even  the  isolation  of  these  cases. 

Protection  of  the  workers  against  the  predisposing  causes  is  the 
duty  of  every  employer  and  should  be  made  legally  compulsory.  This 
is  not  a  hardship  or  an  unjust  demand  on  any  concern  for  protection 
against  this  disease  always  means  an  improved  working  environment, 
a  healthier  more  contented  working  force,  decreased  labor  turn-over 
and  therefore  increased  production.  An  enlightened  business  world 
should  grasp  these  facts  and  voluntarily  protect  the  labor  market 
from  this  and  other  destructive  diseases. 

These  preventive  measures  have  been  set  forth  at  length  in 
numerous  other  places  in  this  book,  especially  under  Industrial 
Hygiene.  In  combating  tuberculosis  the  ventilation  including 
dust  removal,  temperature  and  humidity  and  cleanliness  of  the 
working  rooms  are  the  three  most  important  conditions  for  industry 
in  general  to  consider.  Overcrowded,  dark,  damp,  ill  ventilated, 
stuffy  rooms  have  been  responsible  for  hundreds  of  thousands  of 
deaths  from  phthisis.  These  condilions  plus  dusty  occupations  are 
the  great  allies  of  the  tubercle  bacillus.  So  easy  to  prevent,  and  yet 
what  an  economic  waste  they  have  caused  during  the  centuries. 

In  the  best  conducted  business  these  faults  will  creep  in.  The 
primary  object  of  the  management  is  to  maintain  production.  The 
employees  are  directly  absorbed  with  their  work.  Therefore,  it  is 
necessary  for  the  physician  in  industry  to  concentrate  his  efforts  on 
these  preventive  measures.  Frequent  inspections  of  the  working 
places  must  be  made;  tests  of  the  ventilation,  of  the  temperature 
and  humidity  of  the  atmosphere  must  be  made  a  routine  part  of  his 
work.  In  a  large  concern  it  is  well  to  assign  this  duty  to  one  doctor 
who  must  be  held  responsible  for  maintaining  health  standards  in 
the  working  place.     His  recommendations  should  be  made  to  the 


THE  TUBERCULOUS  EMPLOYEE  443 

highest  authority  in  the  management  and  repeatedly  made  until 
faulty  conditions  are  corrected. 

In  those  occupations  where  dust  or  fumes  are  created,  especially 
when  of  a  known  hazard  to  the  lungs,  every  facility  must  be  provided 
for  the  proper  removal  of  the  same.  These  consist  of  hoods,  large 
conducting  pipes,  suction  fans  and  other  apparatus.  In  some  concerns 
where  great  attention  has  been  given  to  this  hazard,  practically  all 
dust  is  eliminated  from  the  rooms.  Instead  of  throwing  this  dust 
into  the  outside  atmosphere  it  is  often  collected  in  bags  or  rooms 
provided  for  the  purpose  and  salvaged.  This  salvaging  process  alone 
has  paid  many  times  over  for  the  expense  of  installing  the  necessary 
system. 

The  removal  of  dangerous  fumes  is  just  as  essential  for  often  these 
fumes,  as  for  instance,  lead,  will  predispose  to  tuberculosis  even  with- 
out causing  the  specific  occupational  disease. 

A  factory,  with  both  hazards  of  dust  and  of  fumes,  was  recently 
inspected.  The  management  was  very  proud  of  the  fact  that  it  had 
provided  protective  measures  for  the  employees.  The  hoods,  which 
cost  $50,000  to  install,  were  pointed  to  with  pride.  But  these 
hoods  were  some  four  feet  over  the  lead  vats;  other  hoods  for  dust 
removal  were  covered  on  their  exterior  with  the  fine  metal  dust. 
The  dust  that  was  collected  discharged  from  a  pipe  just  outside  the 
building  and  much  of  it  was  blown  back  into  the  room  through  an 
adjacent,  open  window. 

The  physician  should  always  demand  the  services  of  an  expert 
industrial  engineer  to  take  charge  of  installing  ventilation  and  dust 
and  fume  removal  systems.  Concerns  will  meet  the  problems  more 
thoroughly  and  will  save  needless  expense  by  employing  such  engineers. 

The  use  by  employees  of  a  non-irritating,  simple  respirator,  should 
be  enforced  in  all  occupations  where  dust  and  fumes  prevail.  Such 
respirators  are  often  furnished  by  the  employer,  but  no  effort  is  made 
to  compel  their  use. 

Educational  campaigns  among  the  employees  is  the  greatest  means 
of  securing  their  co-operation  in  all  these  preventive  measures. 

Excellent  reports  on  the  reduction  of  disease  in  certain  hazardous 
occupations  by  the  use  of  these  various  devices,  coupled  with  educating 
the  employees  to  their  use  have  been  published  by  the  Pennsylvania 
and  New  Jersey  Departments  of  Industry  and  Labor,  as  well  as  by 
the  United  States  Department  of  Labor,  These  furnish  irrefutable 
evidence  that  tuberculosis  can  be  controlled  in  these  occupations. 
The  next  step  for  these  governmental  agencies  is  to  provide  means 
of  punishment  for  those  industries  which  continue  to  neglect 
precautions. 

The  benefits  derived  from  a  healthful  working  place  may  be  com- 


444  INDUSTRIAL    MEDICINE    AND    SURGERY 

pletely  nullified  by  faulty  home  conditions  and  insanitary  community 
surroundings.  While  the  employer  cannot  be  held  legally  responsible 
for  these,  yet  it  behooves  him  to  see  that  they  are  corrected.  This 
is  another  duty  for  the  medical  staff.  CoHDperation  with  the  city 
and  state  health  authorities  will  improve  community  conditions  which 
should  always  include  housing  conditions.  By  the  aid  of  the  visiting 
nurses,  and  by  subtle  suggestions  from  the  doctors  and  often  by  actual 
assistance  from  the  employer  better  home  conditions  can  be  obtained 
for  most  of  the  employees. 

The  third  great  preventive  measure  which  every  industry,  and  every 
small  employer  should  adopt  is  the  constant  supervision  of  the  physical 
condition  of  the  employees  by  medical  examinations.  The  method 
of  doing  this  is  dealt  with  in  other  chapters.  To  reiterate  though, 
some  system  must  be  established  whereby  every  employee  will  be 
examined  and  re-examined  whenever  necessary.  Those  working  in 
dusty  occupations,  in  rooms  which  must  perforce  be  dark  or  damp, 
or  where  other  hazards  exist,  should  be  examined  at  stated  intervals, 
preferably  every  month,  and  certainly  every  three  months.  These 
examinations  will  enable  the  discovery  of  all  tuberculous  cases  in  an 
early  and  therefore  curable  state.  Combined  with  the  examination 
of  applicants  they  furnish  the  means  of  eliminating  these  cases  from 
the  working  force. 

After  a  man  has  been  cured  of  tuberculosis  he  should  be  allowed  to 
return  to  the  industry  to  work  at  his  old  occupation,  if  no  hazard  for 
the  disease  exists  there,  or  in  some  allied  occupation.  These  apparently 
cured  cases  therefore  furnish  another  group  of  employees  who  should 
be  periodically  examined  to  guard  against  a  recurrence. 

TREATMENT  OF  THE  TUBERCULOUS  EMPLOYEE 

The  elimination  of  the  tuberculous  employees  from  the  working 
place  means  excessive  hardships  for  them  and  their  famihes,  and  often 
is  a  very  decided  contributing  factor  to  their  deaths,  unless  provisions 
are  made  for  their  proper  care,  preferably  in  sanatoria,  and  the 
adequate  support  of  their  dependents  during  the  period  of  treatment. 
Until  recent  years  no  such  provisions  were  made  for  the  treatment 
of  these  cases,  resulting  therefore  in  a  high  death  rate  particularly 
among  the  poor. 

To-day,  chiefly  because  of  the  efforts  of  the  members  of  the  National 
Tuberculosis  Association  and  the  various  state  and  municipal  tuber- 
culosis institutes,  there  are  numerous  sanatoria  scattered  through- 
out the  country  where  free,  or  very  reasonable,  treatment  can  be 
given  to  these  sufferers.  Massachusetts  has  established  such  sana- 
toria in  several  counties  and  plans  to  have  one  in  practically  every 


THE    TUBERCULOUS    EMPLOYEE  445 

county  of  the  state.  A  few  other  states  are  planning  similar  pro- 
visions. Several  state  sanatoria  have  been  established  and  a  few 
county  and  municipal  sanatoria.  Chicago's  Municipal  Sanatorium 
is  one  of  the  most  representative  of  the  latter. 

Adequate  provision  for  the  support  of  the  families  during  the 
period  the  wage  earner  is  under  treatment  has  not  yet  been  made. 
The  reports  of  any  United  Charities  Organization  in  the  country  will 
show  that  they  have  furnished  relief  to  hundreds  of  such  families. 
The  motive  back  of  this  relief  has  been  noble  and  it  was  necessary,  but 
charity  in  any  form  should  not  be  a  part  of  the  social  and  economic 
mechanism  of  our  country.  Charity,  when  interpreted  as  brotherly 
love,  should  provide  sick  insurance  or  some  other  self-respecting  means 
for  the  support  of  these  dependents. 

Even  with  the  establishment  of  these  sanatoria  no  state  has  yet 
provided  the  machinery  for  the  early  discovery  of  the  cases  of 
tuberculosis.  All  authorities  agree  that  the  disease  is  usually  curable 
when  treatment  is  started  in  the  incipient  stage.  In  spite  of  this 
knowledge  the  death  rate  still  continues  high  in  most  sanatoria  because 
the  cases  were  not  admitted  until  the  disease  had  reached  the  second 
or  third  stage. 

The  medical  profession  is  responsible  for  this  condition  in  many 
cases.  Lack  of  ability  to  diagnose  the  disease  in  its  incipiency,  fail- 
ure to  thoroughly  examine  each  patient,  and  temporizing  with  the 
condition  by  trying  ambulatory  or  home  treatment  are  the  three  most 
appalling  mistakes  which  the  family  doctor  makes  with  his  tuberculous 
patients.  The  patients  themselves  often  pay  no  attention  to  the 
early  symptoms,  dragging  about  their  work,  trying  patent  medicines 
and  home  remedies,  and  when  finally  forced  to  consult  a  physician 
the  disease  is  in  an  advanced  form,  often  incurable  or  entailing  a 
heavy  financial  loss  to  both  the  patient  and  the  state  because  of  the 
longer  period  of  treatment  necessary. 

Even  more  essential  than  the  establishing  of  sanatoria  is  for  the 
state  to  provide  the  necessary  machinery  for  the  early  detection  of 
the  consumptive  and  to  make  treatment  compulsory  during  this  early 
stage. 

The  work  of  many  industrial  medical  staffs  has  demonstrated 
the  value  of  periodical  medical  examinations  as  the  best  means  for 
detecting  the  early  cases.  Also  many  concerns  have  provided 
sanatorium  treatment,  free  of  charge,  for  their  tuberculous  employees 
and  have  thus  reduced  the  length  of  treatment  and  the  death  rate  on 
account  of  this  disease  to  a  most  marked  degree. 

Sick  insurance,  based  on  the  fundamental  principle  of  'prevention 
first,  would  undoubtedly  provide  for  the  periodical  exarrJnation  of 
all  workers.     If  the  prevention  idea  is  to  be  the  basis,  sick  insurance 


446  INDUSTRIAL    MEDICINE    AND    SURGERY 

should  be  compulsory  for  everybody.  The  machinery  established 
to  carry  on  this  work  would  be  the  means  of  finding  the  tuberculous 
in  our  midst  in  this  early,  curable  stage. 

Many  municipal  health  departments  provide  consultants  who 
visit  every  contagious  case  reported,  to  ascertain  if  the  diagnosis  is 
correct  and  if  proper  precautions  are  taken.  Physicians  who  fail 
to  report  these  cases  early  are  legally  responsible.  A  similar  plan 
should  be  adopted  in  regard  to  tuberculosis.  Early  reporting,  com- 
petent consultants  to  visit  these  cases  or  centers  where  they  could  be 
referred  for  examination  combined  with  sanatorium  treatment  for 
all  positive  cases,  and  suitable  provisions  for  the  suspicious  ones, 
would  be  one  of  the  greatest  life  saving  measures  which  the  state  could 
adopt.  Punishment  for  the  doctor  failing  to  report  his  tuberculous 
patients  early  would  soon  eliminate  the  majority  of  these  second  and 
third  stage  cases  which  now  seek  sanatorium  care. 

It  is  quite  evident  that  tuberculosis  has  so  many  predisposing 
causes  that  in  the  majority  of  cases  it  is  impossible  to  say  which  one 
has  been  responsible.  Most  of  these  causes  however  are  found  in 
the  social  and  economic  fabric  of  our  every  day  existence.  It  can 
really  be  classed  as  a  social  disease,  the  prevention  and  cure  of  which 
is  a  state  duty. 

In  the  absence  of  the  state  assuming  this  responsibility  we  have 
many  examples  of  wonderful  provisions  for  the  care  of  the  tuberculous 
by  various  organizations,  by  philanthropic  citizens,  and  above  all 
by  certain  individual  industries.  These  latter  have  provided  every 
means  for  prevention  in  the  plant,  and,  when  an  employee  is  assailed, 
every  opportunity  for  the  best  of  treatment.  No  chapter  on  the  tuber- 
culous employee  would  be  complete  without  setting  forth  in  detail 
examples  of  this  care  on  the  part  of  certain  concerns. 

In  1906  an  effort  was  made  by  a  few  of  the  large  manufacturers 
of  Providence,  Rhode  Island,  to  exterminate  tuberculosis  in  their 
factories.  Large  placards  were  placed  in  conspicuous  places  advis- 
ing all  employees  with  suspicious  lung  symptoms  to  report  to  Dr. 
Frank  Fulton,  who  offered  his  services  gratis,  for  examinations.  The 
object  was  to  diagnose  the  disease,  if  possible,  in  its  early  stages.  Some 
eighteen  cases  were  discovered  and  proper  home  and  sanatorium  treat- 
ment established.  As  a  result,  all  of  these  workmen  recovered  and 
were  able  to  return  to  work. 

A  few  years  ago  in  Hartford,  Conneticut,  10,000  employees  of 
various  factories,  mills  and  other  industries  organized  to  protect  them- 
selves and  their  families  from  the  ravages  of  tuberculosis.  The  owners 
of  these  industries  agreed  to  give  a  sum  equal  to  that  raised  by  the 
working  men  and  women  to  fight  the  disease.  Adequate  medical 
aid  was  called  into  service,  and  by  means  of  home  and  sanatorium 


THE  TUBERCULOUS  EMPLOYEE  447 

treatment   they    were  able  to   greatly  reduce  the  death  rate  from 
consumption. 

In  Oxford,  Massachusetts,  a  boot  and  shoe  factory  showed  a  record 
of  one  death  out  of  every  six  of  its  employees  due  to  tuberculosis. 
In  1904  a  systematic  educational  campaign  was  organized  among  the 
workers  in  this  factory,  its  purpose  being  to  instruct  them  as  to  the 
nature,  cause  and  prevention  of  consumption.  Also  the  owners  paid 
for  free  treatment  for  three  months  in  a  sanatorium  for  those  employees 
afflicted  with  the  disease.  As  a  result  the  deaths  greatly  diminished, 
and  in  1907,  three  years  later,  only  four  people  died  of  consumption  in 
Oxford.  A  similar  movement  started  in  Worcester,  Massachusetts, 
showed  equally  marked  results. 

In  1909  the  author  started  a  system  of  medical  examination  of 
employees  in  one  of  the  large  industries  of  Chicago  employing  at 
that  time  about  10,000  people,  and  now  having  approximately  15,000 
employees.  A  great  many  different  types  of  occupations  were  repre- 
sented here,  including  clerical  work  of  all  kinds,  printing,  packing, 
warehouse  work,  all  kinds  of  merchandizing  and  approximately  forty 
different  manufacturing  processes.  Examples  of  a  majority  of  the 
occupational  hazards  could  be  found  in  this  plant. 

The  medical  examinations  were  first  made  for  the  purpose  of  dis- 
covering the  tuberculous  employee,  but  it  soon  extended  into  a 
thorough  examination  in  order  to  discover  all  other  physical  defects. 
After  three  years,  in  1912,  the  medical  examination  of  all  applicants 
for  work  was  introduced,  and  now  is  one  of  the  most  vital  functions  of 
the  medical  staff  of  this  industry. 

From  January,  1909  to  the  end  of  December,  1917,  869  cases  of 
tuberculosis  were  discovered  among  these  employees  or  applicants  for 
work. 

Since  1912,  245  of  these  cases  were  found  among  the  appUcants,  0.7 
per  cent,  of  all  examined.  About  sixty  of  these  cases  were  not  posi- 
tively diagnosed,  but  had  such  unmistakable  signs  of  the  disease  that 
they  were  rejected.  Others  with  suspicious  findings  in  the  lungs,  yet 
apparently  healthy,  were  employed  but  were  re-examined  at  frequent 
intervals  until  the  signs  cleared  up,  or  a  positive  diagnosis  could  be 
made.  This  policy  accounts  for  the  fact  that  the  highest  percentage 
of  cases  found  in  the  old  working  force  has  been  among  the  three  to 
twelve  months  employees.  So  rnany  suspicious  cases  clear  up  how- 
ever that  a  great  injustice  would  be  done  these  applicants  if  they 
were  rejected  for  lung  trouble.  This  also  accounts  for  the  lower 
tuberculosis  rate  among  these  applicants  (0.7  per  cent.)  as  compared 
with  the  rate  among  the  total  examinations  made  (1.7  per  cent.). 

The  medical  staff  reported  all  of  these  applicants  to  the  City 
Health  authorities  and  to  the  Chicago  Tuberculosis  Institute.     The 


448  INDUSTRIAL    MEDICINE    AND    SURGERY 

visting  nurse  followed  up  all  cases  to  see  that  they  were  under  some 
form  of  supervision.  It  is  a  waste  to  all  industries  to  throw  these 
tuberculous  cases  back  into  society  without  endeavoring  to  place 
them  under  proper  treatment.  If  every  concern  would  adopt  this 
system  they  would  protect  one  another  from  the  contamination  of 
their  employees  by  the  diseased  employee  of  some  other  plant. 
Your  tuberculous  employee  may  occupy  the  same  boarding  house,  may 
even  sleep  with  one  of  the  force  of  another  plant.  The  ramifications 
of  the  spread  of  the  disease  are  so  intricate  that  a  good  business  sense 
should  dictate  a  policy  of  joining  hands  against  this  common  enemy. 
The  624  cases  of  tuberculosis  among  the  old  employees  were 
divided  as  follows: 

Table  12 

Suspected  tuberculosis 94 

Pulmonary  tuberculosis 

first  stage 321 

second  stage 128 

third  stage 44 

Tuberculous  glands 23 

Tuberculous  bones 6 

Tuberculous  spine 3 

Tuberculous  meningitis 

Tuberculous  peritonitis 

Tuberculous  kidney 

Tuberculous  eye 

Tuberculous  tonsil 

624 

The  94  suspected  cases  gave  the  clinical  findings  of  tuberculosis, 
but  were  never  positively  diagnosed.  These  cases,  however,  were 
sufficiently  suspicious  to  be  eliminated  from  the  working  force  and 
placed  under  active  treatment  until  they  had  recovered.  The  ma- 
jority of  these  were  given  home  treatment,  and  later,  when  it  was 
safe  to  stop  more  careful  medical  supervision,  they  were  often  sent  to 
the  country. 

Hundreds  of  cases,  not  shown  in  the  above  table,  were  found  with 
symptoms  indicating  a  threatened  tuberculous  condition.  For 
instance,  many  employees  would  become  anemic,  lose  weight,  complain 
of  night  sweats  or  stomach  trouble,  and  other  symptoms,  pointing  to  a 
generally  run  down  condition.  No  definite  diagnosis  could  be  made, 
but  nevertheless  vacations  were  secured  for  them,  and  they  were 
placed  on  a  general  building  up  regime,  many  going  to  the  country 
to  rest  and  recuperate.  Unquestionably  a  number  of  such  employees 
would  have  developed  an  active  tuberculosis  if  they  had  not  been 
detected  at  this  stage  and  these  precautions  taken. 


THE    TUBERCULOUS    EMPLOYEE 


449 


From  the  very  beginning  of  this  work  this  concern  provided 
free  treatment  for  4  tuberculous  employees.  While  their  occupations 
were  not  responsible  for  the  condition,  except  in  a  very  few  instances, 
yet  the  fact  that  these  people  were  forced  to  quit  work  for  the 
protection  of  the  rest  of  the  employees,  caused  the  management  to  feel 
a  certain  moral  responsibility  for  their  care.  The  first  two  years 
this  free  treatment  was  given  only  to  those  employees  who  had  worked 
for  the  concern  more  than  one  year,  but  since  then  every  case  was 
offered  the  free  treatment.     Except  in  a  few  of  the  early  stage  cases 


Fig.  60.- 


-A  tuberculous  employee  under  treatment  at  home. 
•  her  bi-weekly  call. 


The  visiting  nurse  on 


with  unusually  good  home  surroundings,  or  where  the  employee 
was  from  the  country  and  it  seemed  advisable  for  him  to  return 
there,  sanatorium  treatment  was  advised  for  all.  Many  at  first  refused 
to  go  to  a  sanatorium,  but  each  succeeding  year  made  it  easier  to 
persuade  the  tuberculous  employee  to  accept  this  form  of  treatment. 
For  those  who  refused  to  go  arrangements  were  made  for  proper  treat- 
ment at  home,  either  directly  under  the  care  of  the  medical  staff  or 
under  their  family  physician.  The  visiting  nurse  was  of  the  greatest 
help  in  supervising  this  treatment  in  either  plan.     (See  Fig.  60.) 

Often  the  home  conditions  were  totally  unfit  for  the  proper  treat- 
ment  of  the  case;  or  were  not  suitable  for  the  patient  to  return   to 

29 


450 


INDUSTRIAL    MEDICINE    AND    SURGERY 


after  completing  the  sanatorium  care.  The  doctor  reported  these 
conditions  to  the  management  and  in  almost  every  instance  the 
family  was  persuaded  to  move  to  better  surroundings.  Money  was 
furnished,  whenever  necessary,  to  stand  the  expense  of  moving  and  of 
preparing  a  suitable  sleeping  porch  for  the  patient.  At  first  consider- 
able difficulty  was  encountered  with  many  family  physicians,  but  of 
recent    years   these   doctors  have   co-operated   in   the  work   chiefly 


Fig.  61.- 


-A  tent  erected  in  the  rear  of  a  flat  building  where  a  tuberculous  employee 
after  returning  from  the  sanatorium  continued  his  treatment. 


because  they  know  that  every  facility  for  properly  diagnosing  the 
case  is  used  by  the  medical  staff  and  that  the  treatment  afforded  by 
them  gives  better  results  than  any  home  treatment  which  they  can 
offer. 

The  530  cases  which  were  positively  diagnosed  were  treated  in  the 
following  places: 

Table  13 

In  sanatorium 370 

At   home 108 

In  the  country 40 

Lost  track  of 12 

Total 530 


THE  TUBERCULOUS  EMPLOYEE  451 

The  first  two  years  of  this  experience  only  thirty-four  cases  out 
of  one  hundred  and  sixteen  consented  to  sanatorium  treatment, 
whereas  in  the  last  two  years,  one  hundred  and  twenty  of  the  tubercu- 
lous employees  accepted  the  offer  of  free  sanatorium  care  out  of  one 
hundred  forty-two  cases.  This  proves  the  value  of  educational 
work  among  the  employees  and  also  is  positive  proof  of  the  good 
results  obtained. 

The  sanatoria  chiefly  used  were  Edward  Tuberculosis  Sanatorium 
at  Naperville,  Illinois,  the  Winifield  (Illinois)  Sanatorium  belonging 
to  the  Chicago  Jewish  Aid  Society,  the  Chicago  Fresh  Air  Sanatorium, 
the  Valmora  Sanatorium  of  Watrous,  New  Mexico,  and  others.  All 
but  sixty  of  the  cases  were  treated  in  home  climates.  There  was 
practically  no  difference  in  the  results  obtained  between  the  local 
climatic  conditions  and  those  afforded  by  the  high  altitude  and  climate 
of  the  West.  The  greater  willingness  of  the  employees  to  go  to  a 
sanatorium  near  home  and  the  happier  frame  of  mind  on  the  part  of 
both  the  patients  and  their  families  has  caused  us  to  favor  treatment 
in  their  home  territory. 

The  results  of  this  treatment  are  shown  in  Table  13. 

Table  14 

Cured 236 

Arrested 67 

Improved 44 

Unimproved 5 

Deaths 30 

Lost  trace  of 113* 

Still  under  treatment 33 

Total 530 

The  average  length  of  treatment  for  patients  in  sanatoria  was  six 
months;  and  for  those  receiving  non-sanatorium  treatment  ten  and 
two-third  months.  Of  the  total  number  of  employees  who  have 
received  treatment  approximately  two  hundred  fifty  have  returned 
to  work  in  the  same  concern,  at  their  old  occupations  or  in  some  other 
position  less  hazardous.  There  have  been  twenty  recurrences  among 
those  cases  kept  under  observation  and  in  all  but  three  of  these  the 
disease  has  again  been  arrested.  This  is  a  far  lower  recurrence  rate 
than  is  usually  found  in  this  disease,  thus  demonstrating  the  value  of 
health  supervision.  The  use  of  short  vacations  when  threatening 
symptoms  developed  prevented  many  of  these  employees  from  break- 
ing down. 

Twenty-nine  out  of  the  forty-four  third  stage  or  advanced  cases 
were  found  during  the  first  two  years  of  this  work.     Ten  of  the  deaths 

*Since  their  discharge  from  treatment. 


452 


INDUSTRIAL    MEDICINE    AND    SURGERY 


occurred  during  the  first  two  years  the  remaining  twenty  deaths  were 
scattered  through  the  last  seven  years.     (See  Fig.  62.) 

These  two  facts  substantiate  the  claim  that  physical  examination  of 
employees  enables  the  discovery  of  tuberculous  cases  in  the  earlier 
stages,  thereby  reducing  the  death  rate,  and  shortening  the  time  of 
treatment  necessary  for  a  cure. 


Yio,  62. — Reduction  in  number  of  cases  of  tuberculosis  found  and  in  the  death  rate 
as  number  of  employees  examined  increases.  1,  Per  cent,  of  employees  examined  from 
total  number.  2,  Per  cent,  of  tuberculous  employees  found  among  number  examined. 
3,  Per  cent,  of  deaths  among  those  found  tuberculous. 

The  age  periods  at  which  these  tuberculous  cases  were  found  were 
as  follows: 


Table   15 


Age 
15-20. 
20-25. 
25-30. 
30-35. 
35-40. 
40-45. 
45-50. 
50  or  ( 


Per  cent,  of  cases 

... .  21.0 
. . . ,  34.4 
. .. .  23.9 
.. . .  8.0 
....     5.0 

4.1 

....  3.0 
....      0.5 


While  the  tuberculosis  rate  decreased  markedly  after  the  age  of  35, 
yet  the  discovery  of  this  disease  among  the  applicants  and  new 
employees  resulted  in  a  very  noticeable  reduction  in  the  incidence 
among  the  older  force.  For  example  in  1909  there  were  only  five 
hundred  ten  employees- who  had  worked  at  the  plant  for  five  years 
or  more,  but  33  per  cent,  of  our  tuberculous  employees  were  found 
among  these.     Six  years  later,  in   1914,  there  were  two  thousand 


THE  TUBERCULOUS  EMPLOYEE 


453 


W 


Sears  shack,  Edwards  Sanatorium,  Naperville,  111. 


'■  — 

-^ 

I     "  ' 

'•■'   --^^ 

1  -- 

|lhHW!Hl 

ffllFflfflL-. 

1 

^.^ ^^..^ 

1 

1 

Fig.  63. — Plan  of  sleeping  shack  for  six  patients. 


454  INDUSTRIAL    MEDICINE    AND    SURGERY 

forty-nine  people  who  had  worked  here  for  five  years  or  longer,  and 
only  13.8  per  cent,  of  the  tuberculous  were  among  this  number. 
This  result  was  obtained  by  constant  health  supervision,  by  eliminating 
the  tuberculous  applicant  and  by  improved  working  conditions. 
Fig.  52  illustrates  very  graphically  this  decrease  in  tuberculosis 
among  the  older  employees  and  also  shows  the  great  advantage  to 
the  concern  of  examining  applicants  for  work.  There  were  only 
eight  hundred  thorough  examinations  made  in  1909  when  one  physician 
was  employed,  whereas  in  1914,  with  six  physicians,  twelve  thousand 
three  hundred  eighty  complete  examinations  were  made. 

The  results  obtained  from  discovering  and  reclaiming  the  tuber- 
culous employees  in  this  concern  has  been  one  of  the  most  gratifying 
features  of  the  medical  work.  The  co-operation  of  the  manage- 
ment has  at  all  times  been  of  the  greatest  aid,  and  their  example  has 
influenced  other  industries,  especially  in  Chicago,  to  adopt  a  similar 
program. 

In  1910  because  of  the  limited  capacity  in  Sanatoria  great  difficulty 
was  experienced  in  securing  prompt  admission  of  our  patients.  The 
result  was  that  the  management  erected  a  shack  at  the  Edward 
Sanatorium  for  the  accommodation  of  more  patients.  Since  then  the 
Chicago  Telephone  Company,  the  International  Harvester  Company, 
Montgomery  Ward  and  Company,  and  Swift  and  Company  have  each 
built  shacks  at  this  sanatorium  for  the  use  of  their  employees.  (See 
Fig.  63.) 

In  1911  thirty  of  Chicago's  largest  industries  contributed  the  funds 
for  the  establishment  of  a  sanatorium  at  Watrous,  New  Mexico, 
where  their  employees  could  receive  treatment  at  the  lowest  possible 
cost.  This  is  known  as  Valmora  Sanatorium.  Over  four  hundred 
employees  of  these  concerns,  or  members  of  their  families,  have  received 
treatment  at  Valmora  during  the  last  nine  years  and  the  results  have 
been  most  excellent.  This  was  one  of  the  first  sanatoria  to  adopt 
graduated  exercise,  in  the  form  of  work,  for  its  patients.     (See  Fig.  64.) 

In  1915  the  Ford  Motor  Company  introduced  this  plan  of  giving 
free  sanatorium  care  to  every  tuberculous  employee.  It  has  even 
extended  this  policy  to  the  tuberculous  applicant  for  work.  A  sana- 
toriuni  near  Detroit  has  been  developed  where  these  employees  are 
sent  until  the  disease  is  arrested.  They  then  return  to  the  plant,  are 
put  to  work  in  some  outside  occupation  and  are  carefully  supervised 
by  the  medical  staff.  Most  of  these  cases  have  been  placed  on  the 
work  of  salvaging  the  scrap  iron  which  previously  was  sold  as  junk. 
This  salvaging  process,  done  by  salvaged  employees,  netted  this 
concern  a  profit  of  $78,000  in  one  year.  Large  dividends  from  a  simple 
humanitarian  effort!  The  profit  to  these  employees  and  their  families 
cannot  be  shown  in  dollars  and  cents.     (See  Fig.  65.) 


THE    TUBERCULOUS    EMPLOYEE 


455 


,fe    a^ 


^'^       .  .^ 


,456 


INDUSTRIAL    MEDICINE    AND    SURGERY 


The  Jewish  Tuberculous  Association  of  New  York  City  has 
introduced  an  entirely  new  idea  into  the  treatment  of  this  disease. 
After  years"  of  combating  tuberculosis  among  the  Jewish  people  of  New 
York  they  were  impressed  with  the  great  economic  waste  which  fol- 
lowed in  the  wake  of  this  disease.  During  the  perod  of  sanatorium 
care  it  was  necessary  to  give  large  sums  of  money  to  maintain  the 
family  while  the  bread  winner  was  absent.  After  his  discharge  from 
treatment  months  and  often  years  elapsed  before  he  could  support 
his  family.     Investigation   showed   that   most   of  these  patients  on 


Fig.  65. — Tuberculous  employees  at  work.      (Courtesy  of  Ford  Co.) 


discharge  from  sanatoria  were  warned  against  returning  to  inside 
employment.  They  sought  work  on  farms,  as  teamsters  and  at  other 
outside  occupations,  positions  for  which  they  were  untrained  and 
physically  unfitted.  Jobs  were  frequently  changed  because  they  were 
not  able  to  do  the  work.  Exposure  to  the  elements,  worry  and  other 
undermining  conditions  caused  a  high  percentage  of  recurrences. 

In  order  to  overcome  this  economic  waste  and  unnecessary  loss 
of  human  life  this  Association,  through  the  magnificent  efforts  of  Mr. 
Stein  and  Mr.  Hockhauser,  developed  a  postsanatorium  factory. 
This  factory  is  located  in  Hoboken,  and  is  engaged  in  the  manufacture 
of  garments.  Here  under  the  best  hygienic  conditions,  and  constantly 
supervised  by  a  competent  doctor,  over  two  hundred  tuberculous 
employees  have  been  given  graduated  work  until  they  were  finally 


THE  TUBERCULOUS  EMPLOYEE 


457 


able  to  return  to  full  time  employment  when  they  graduated  from 
the  factory.  Tinsmiths,  clerks,  jewelers,  junk  men  and  many  others 
have  learned  to  be  garment  makers  and  are  drawing  larger  salaries 
now  than  they  made  previous  to  their  sickness.  This  factory  has 
demonstrated  that  the  garment  industry  when  properly  conducted  is 
not  a  hazardous  occupation  predisposing  to  lung  trouble.  (See  Figs. 
66  and  67.) 

The  summary  and  chart — taken  from  a  paper  by  Mr.  Hockhauser 
on  this  experiment  is  one  of  the  most  enlightening  contributions 
to  all  tuberculosis  literature. 


Fig.  66. 


-Model    garment    factory    for    tuberculous    employees. 
Tuberculous  Association.) 


{Courtesy    Jewish 


"An  investigation  in  1912  reported  a  waste  of  45  per  cent,  due  to 
relapse  of  sanatoria  patients  six  months  to  one  year  after  discharge. 
In  a  three  year  experiment  we  have  reduced  it  from  45  per  cent,  to  15 
per  cent. 

"The  sanatorium  treatment  is  but  a  part — a  large  part  it  is  true — 
of  the  treatment  of  the  tuberculous. 

"After-care  of  the  patient  in  his  home  is  vital  to  any  scheme  which 
tries  to  conserve  the  gains  made  in  the  sanatorium  and  to  protect  the 
family  from  infection. 

"Carefully  selected  patients  can  be  treated  at  home  with  as  good 
results  as  at  a  sanatorium.  Some  patients  improve  at  home  and  at 
work  even  though  they  do  not  do  well  at  an  institution. 


458 


INDUSTRIAL    MEDICINE    AND    SURGERY 


"To  provide  'industrial  convalescence'  or  a  scheme  of  gradually 
returning  patients  to  ordinary  economic  life  we  maintain  a  special 
factory  where  the  doctor  is  the  '  boss. ' 

"Over  90  per  cent,  of  the  families  of  the  patients  at  the  factory  were 
under  the  care  of  relief  agencies.  Of  58  who  received  relief  from  three 
months  to  five  years  17  are  partially  self-supporting  and  41  are  entirely 
self-supporting.  Patients,  whose  families  were  granted  from  $40  to 
a  month  by  charities  and  relief  agencies,  are  now  earning  from 

to  $160  a  month. 


Fig.   67. — Dining  room  in  model  garment  factory  for  tuberculous  employees. 

"Periodic  examination  of  the  patient  is  the  price  of  keeping  the 
tuberculous  at  work.  The  doctor  must  know  his  patients  to  guard 
against  the  malingerer  or  the  patient  too  anxious  to  work  to  be  truthful. 

Generous  constructive  care  and  supervision  can  cure  dependency 
as  well  as  tuberculosis. " 

All  surgeons  in  industry  as  well  as  the  tuberculosis  worker  have 
been  impressed  with  this  great  waste  of  human  energy  as  well  as  of 
human  Ufe  and  its  resulting  financial  losses  to  the  patient,  his  family 
and  the  state,  which  has  been  connected  with  the  treatment  of  4 
tuberculous  people.  Not  only  is  it  essential  for  the  states  to  provide 
adequate  Sanatoria  care  for  all  tuberculous  but  it  should  see  that  these 
people  are  placed  in  proper  employment  and  carefully  supervised 
after  their  treatment  ceases.  The  prevention  of  recurrences  is  equally 
as  essential  as  the  cure. 


THE    TUBERCULOUS    EMPLOYEE 


459 


T-,  ^ 


o     o 
o  oo 

^ 

CO     rH 

^ 

CO 

M 

>! 

io"^ci 

•H 

T3  M 

—  a 

(N       ■* 

^     o 

3  a 

q  oo 

CO 

lO        ■    ^ 

CO 

CO 

-r 

'^"    : 

°2 

rH        rq 

£>> 

o  OO 

1-4 

C<)       • 

T-H      I— ( 

Th 

Oi 

IM     rH 

-f 

d^'S 

i-< 

§^§ 

(M 

CO 

CO 

oi"ii 

S 

o 

2§ 

I— ( 

<N       ■ 

CO 

is 

^^.a 

di^ 

=3   .  a 

■«ES 

°  m 

o 

iM 

CI 

*-  03 

H 

< 

CO 

: 

fi^ 

c5  >, 

1 

h 

S 
p 

23 

—  a) 
u2  9* 

si 

m 

m 

03 

(M 

CO 

1— 1 

ffi  & 

03 

CI 

o 

— 



O 

o 

— 

rt 

_  o 

< 

aiq'Buoi:>sanl) 

o 
CO 

CD 

o 

a 

CO 

-    : 

Tfl 

^ 

o 

O 
-     +J 

O 



o 

<ii 

CO 

lO 

t^ 

IM 

-t^ 

(3 

aAi:jo'Buj 

(M 

I— 1 

;     7-H 

>. 

T-( 

CO 

lO     iH 

^ 

'  'O 

o 
o 

a 

o 

03 

O 

o 

o3 

O 

o 

03 

— 

o 

o3 

S5 

pa^eajjB 
ddy 

< 

Tt4 

CO    ,-1 

< 

»c     ; 

-1^ 

< 

CD 

»o 

"3    : 

^ 

Ph 

o 

■  i^ 

ajno   ddy 

(M 

CO    :  .- 

CD 

H 

< 

^ 

o  g 

»— I 

CO 

CO 

O 

lO 

lO     ^     .-H 

<N     r-l 

1—1 

t>-     tH 

o 

M  a) 

i-i 

CD 

1—1 

"* 

CO 

H 

" 

CO 

"3 

cc    : 

i-l 

1—1 

^    : 

t^ 

;?^ 

1— 1 

anioq 

,_, 

1—1 

1—1 

(N 

IC 

^■B  pa:jBaj^  9omg 

H 

< 

Plh 

ninijo^'Bu'BS 

i> 

O     T-H     ^ 
T— 1 

Tt<  1-1 

CO 

Tl< 

Oi    rH 

03 

rl 

en 

£     • 

2  s 
=«  s? 

o 

•       0! 

if\ 

^   £ 

03 

s 

03      03 

0) 
>> 

<u 
<1) 

ur  ye 

e  yea 
ears . 

3^  s 

0) 

Sh 

e  to  fo 
to  fiv 
five  V 

t-     o 

o 

O     t- 

4^ 

^    o 

^ 

1^ 

o 

o  -^ 

o 

5^ 

p 

^-     3     4. 

o    t 

(U 

s 

<»     5 

^ 

^     O     > 

&  ^ 

a 

,£3 

fl     & 

H  H  E^  C 

Eh  Eh 

O 

Eh  O  Eh 

-a 

(d 

hr 

o3 

Cl 

03 

a; 

03 

-tJ 

rA 

OI 

3 

■n 

tPl 

crt 

03 

bX) 

a 

c 

d 

O 

tj 

^ 

o 

at 

d 

t^ 

fl 

1—1 

03 

-o 

l=! 

a> 

lA 

rrt 

ii 

m 

Tt< 

cj 

»o 

(U 

m 

OI 

Tl 

rt 

a> 

<D 

^ 

->^ 

+-> 

it! 

(4-) 

a 

o 

03 

rr 

0) 

«J-. 

C 

n 

03 

> 

460 


INDUSTRIAL    MEDICINE    AND    SURGERY 


The  establishing  therefore  of  industries  in  certain  centers  where 
these  ex-sanatoria  patients  could  be  sent  for  graduated  employment 
under  proper  medical  supervision  is  a  duty  which  should  no  longer 
be  neglected.  Those  states  which  are  providing  sanatoria  for  the 
tuberculous  should  at  once  provide  these  state  industries  where  they 
can  work  until  such  time  as  it  is  safe  for  them  to  return  to  private 
employment  (F  g.  68). 

It  is  a  fallacy  to  recommend  outdoor  employment  such  as  farming 
for  all  arrested  or  apparently  cured  tuberculous  patients.     Many  of 


Fig.  68. — Every   state   should   provide   these   model   factories   for   the   tuberculous  in 
connection  with  the  state  sanatoria. 


these  are  not  vocationally  trained  or  physically  fit  for  the  strenuous  out- 
side work  and  to  others  it  is  abhorrent.  Experience  in  caring  for  the 
tuberculous  employee  has  proven  that  the  majority  of  these  can 
return  to  their  former  occupations  providing  there  are  no  known 
hazards  connected  with  it. 

Society  owes  an  everlasting  debt  of  gratitude  to  those  industries 
which  have  provided  the  means  of  Prevention,  Discovery  and  Treat- 
ment of  the  Tuberculous  Employees. 


CHAPTER  XXX 

RECLAIMING  THE  TUBERCULOUS  SOLDIER  FROM 
THE  MILITARY  AND  INDUSTRIAL  ARMIES 

The  army  is  a  great  military  industry  made  necessary  by  the  pres- 
ent struggle  of  right  against  might.  Its  medical  problems  are  very 
similar  to  those  found  in  the  industrial  army.  The  solution  of  these 
problems  for  the  soldier  is  destined  to  carry  over  into  civilian  life. 
Therefore,  in  considering  the  reclamation  of  the  tuberculous  at  this 
time  it  is  only  logical  to  deal  with  the  entire  man  power  in  both  armies. 

The  war  has  brought  to  public  attention  a  great  many  disabilities 
which  overtake  the  soldier  as  the  result  of  military  service.  Some  of 
these  disabilities  and  our  efforts  to  overcome  them  are  in  the  lime- 
light more  than  others. '  Thus,  the  reconstruction  of  the  badly  crip- 
pled, the  deformed,  and  those  suffering  severe  facial  disfigurations, 
is  wonderful  and  quite  spectacular  to  the  general  public;  the  retrain- 
ing of  the  limbless  and  of  the  blind  likewise  appeals  to  our  minds  and 
imaginations.  But  just  as  wonderful  work  is  being  done  for  those 
soldiers  disabled  because  of  disease  and  the  number  of  these  far  exceeds 
those  who  are  crippled  or  blinded. 

These  same  disabilities  existed  before  the  war,  but  the  busy  pub- 
he  paid  very  little  attention  to  them  except  when  they  or  their  friends 
were  the  victims. 

But  our  efforts  to  prevent  disease  among  the  soldiers,  and  when 
disabilities  overtake  them,  to  reconstruct,  and  when  necessary  retrain 
them  for  a  Hfe  of  usefulness,  are  gradually  awakening  the  public  con- 
science to  the  need  for  the  same  efforts  among  the  civilian  disabled. 

The  disease  which  is  causing  the  most  disability  among  the  sol- 
diers of  all  the  nations  is  tuberculosis.  We  have  not  been  in  the  war  a 
sufficient  time  to  realize  the  terrible  ravages  of  this  disease  among 
the  military  and  civilian  forces  alike,  but  the  experience  of  our  allies  is 
sufficient  warning  to  point  out  the  importance  of  our  preparing  to 
combat  tuberculosis  and  its  complications. 

It  is  difficult  to  obtain  exact  statistics  concerning  the  incidence  of 
tuberculosis  in  the  warring  nations.  A  conservative  estimate  re- 
cently made  by  one  of  our  greatest  tuberculosis  experts,  Dr.  Briggs, 
who  studied  conditions  at  first  hand  in  Europe,  showed  that  there  are 
at   least   500,000   active  cases  of  tuberculosis  in  France.     England 

461 


462  INDUSTRIAL    MEDICINE    AND    SURGERY 

shows  an  increase  of  16  per  cent,  in  the  death  rate  from  pulmonary 
tuberculosis  as  compared  with  the  rate  of  1914. 

The  Canadian  forces  have  already  sent  2500  cases  of  tuberculosis 
back  to  the  sanatoria  in  Canada  for  treatment.  Fifty  per  cent,  of 
these  were  discovered  among  the  soldiers  before  they  had  been  sent 
overseas. 

Many  cases  of  tuberculosis  have  been  discovered  among  our  own 
soldiers.  The  epidemics  of  measles,  grip  and  pneumonia  which  have 
been  so  prevalent  throughout  the  cantonments,  will  increase  the  tuber- 
culosis rate  materially. 

In  the  light  of  the  above  facts  and  figures  it  is  imperative  that  the 
plans  of  the  medical  department  of  the  army  be  formed  along  three 
distinct  lines:  prevention,  reclaiming,  and  coordination  with  civilian 
plans. 

As  a  result  of  the  work  of  the  National  Tuberculosis  Association 
during  the  last  fifteen  years  the  national  conscience  has  been  stirred, 
the  public  has  been  educated  to  means  of  prevention  and  cure  of  tuber- 
culosis, and  the  soil  has  been  generally  prepared.  A  great  harvest 
of  results  awaits  the  reapers. 

In  addition  to  this  publicity  and  missionary  work  almost  every 
large  city  of  the  country  now  has  its  tuberculosis  institutes,  many 
county  institutes  have  been  formed  and  much  valuable  machinery 
in  the  way  of  medical  experts  and  visiting  nurses  has  been  established 
for  the  purpose  of  fighting  this  disease.  A  number  of  municipal  and 
state  sanatoria  have  been  erected.  A  few  states  like  Massachusetts 
have  made  elaborate  plans  for  a  sanatorium  in  practically  every 
county  or  group  of  counties  and  have  many  of  these  in  operation. 
Large  appropriations  by  some  of  the  states  have  been  made. 

Meanwhile,  the  medical  profession  has  made  great  advances  in 
the  treatment  of  this  disease.  No  longer  is  it  considered  fatal.  No 
longer  do  we  think  it  necessary  to  send  the  tuberculous  patient  out 
west  or  far  from  home  in  order  to  accomplish  a  cure.  Homesickness 
and  want  have  ceased  to  be  the  great  allies  of  Death  in  treating 
these  cases. 

Climatic  treatment,  many  different  drugs  and  serums,  and  other 
specifics  have  come  and  gone  during  these  years.  Theories  as  to 
modes  of  infection  and  as  to  the  spreading  of  infection  have  been 
advanced  and  discarded,  and  some  remain  for  the  proverbial  bone 
of  contention.  Absolute  rest  for  months  has  been  advocated  by 
some,  and  early  exercise  and  work  is  the  criterion  of  others  as 
adjuncts  to  various  forms  of  treatment. 

But  a  few  sound,  common  sense  principles  have  been  evolved  and 
have  withstood  the  acid  test  of  time  and  criticism,  and  will  remain 
as  the  fundamentals  in  our  crusade  against  this  disease.     These  are: 


RECLAIMING    THE    TUBERCULOUS    SOLDIER  463 

1.  Prevention. 

(a)  By  combating  unsanitary  home  and    working   conditions, 

child    labor,    inadequate   food,    alcoholism,    and   venereal 

diseases. 
(6)   By  preventing  the  spread  of  the  disease  from  one  infected 

person  to  another, 
(c)   By  active  and  thorough  treatment  of   those   respiratory 

diseases  predisposing  to  tuberculosis. 

2.  Diagnosis. 

(a)  The  importance  of  an  early  diagnosis. 

(6)  The   value   of   the   periodical    medical    examination    as   a 

means  of  early  diagnosis, 
(c)   The  importance  of  medical  examination  of  other  members 

of  the  family  when  a  case  is  discovered. 

3.  Treatment. 

(a)  The  instituting  of  early  sanatorium  treatment. 

(b)  The   value   of  isolation   of  the  case  from  free  intercourse 
with  society. 

(c)  The  established  routine  of  Rest,  Fresh  Air,  Proper  Diet 
combined  with  graduated  exercise  later  on. 

(d)  The  importance  of  supervision  of  the  apparently  cured  c'ase 
for  many  years. 

All  of  these  things  with  many  additional  details  the  tuberculosis 
expert  and  his  lay  and  nurse  assistants  do  to-day.  The  treatment 
laps  over  into  the  social  and  economic  field.  Thus,  the  tuberculosis 
institutes,  and  other  groups  of  workers  in  this  field,  have  banded  -to- 
gether to  efficiently  handle  the  medical,  social  and  economic  aspects 
of  this  disease.  They  treat  not  only  the  individual  but  society  at 
large. 

A  wonderful  work  has  been  accomplished  by  these  organizations 
all  over  the  country  but  the  surface  has  only  been  scratched.  Their 
cases  have  come  to  them  voluntarily  or  been  referred  by  charitable 
organizations.  The  weakness  of  the  system  has  been  the  absence 
of  some  form  of  governmental  control — federal  and  state. 

The  discovery  of  approximately  two  hundred  thousand  cases  of 
tuberculosis  among  the  first  ten  million  men  between  twenty-one  and 
thirty-one  examined  for  the  draft  army  showed  the  enormity  of  the 
task  before  us.  Thousands  upon  thousands  of  young  men  have  been 
thrown  back  into  civilian  life  suffering  from  tuberculosis.  Some 
have  been  referred  to  the  proper  authorities  for  treatment,  but  many 
remain  loose  in  society  to  combat  the  disease  according  to  their 
individual  desires — sources  of  infection  to  their  fellowmen.  What 
an  economic  waste  of  man-power  in  this  day  when  man-power  is  at 
such  a  premium. 


464  INDUSTRIAL    MEDICINE    AND    SURGERY    . 

Therefore,  the  first  contact  that  should  be  established  and  cemented 
most  firmly  between  the  military  and  civilian  forces  is  apparent — 
the  reporting  of  every  man  rejected  from  the  army  because  of  tuberculosis 
to  an  authorized  civilian  agency. 

This  agency  must  provide  in  every  state  suitable  sanatoria  and 
proper  medical  attention  for  the  treatment  of  these  cases  until  cured. 
The  state  should  make  such  a  course  of  treatment  compulsory.  The 
mistake  of  our  allies  in  allowing  them  to  go  untreated,  spreading 
the  infection  to  others,  must  not  be  repeated  by  us.  Such  a  mistake 
has  already  been  made  but  it  is  not  too  late  for  correction. 

For  years  we  have  dreamed  of  a  nation  striving  constantly  to 
prevent  tuberculosis.  We  have  dreamed  further  of  an  elaborate 
system,  of  sanatoria  scattered  throughout  the  nation  for  the  cure 
of  these  cases.  To-day  the  demand  for  the  conservation  of  our 
man-power  makes  it  absolutely  essential  that  our  dreams  become 
realities. 

This  is  a  national  emergency  and  all  things  looking  to  the  winning 
of  this  war,  either  by  sacrifice  or  by  saving,  can  be  established  now. 
This  is  the  time  to  get  together  and  do  it. 

All  tuberculosis  associations  should  cooperate  with  the  United 
States  Public  Health  Service,  the  National  Defense  Council,  the 
American  Red  Cross,  the  organized  medical  profession,  and  all  other 
agencies  capable  of  contributing  to  the  effort,  and  institute  a  great 
drive  against  tuberculosis  now  rather  than  two  years  hence  when  the 
increased  number  of  cases  will  force  cognizance  of  conditions  as  it  has 
done  in  France  and  England. 

There  is  still  another  civilian  force  that  has  been  doing  excellent 
work  in  the  tuberculosis  field —  a  force  that  has  made  itself  felt  more 
and  more  during  the  last  decade  in  both  the  medical  and  economic 
world.  I  refer  to  the  industrial  physicians  and  surgeons  of  the  country. 
Not  the  oldtime  company  doctor  who  constantly  thought  of  the 
interests  of  the  employer  alone,  contenting  himself  with  the  emergency 
surgery  that  arose  in  the  plant,  but  the  new  industrial  medical  man 
who  speaks  the  language  of  preventive  medicine  and  preventive 
surgery,  who  is  the  employees'  physician,  and  who  has  become  a 
great  efficiency  expert  for  the  employer  by  constantly  thinking  of  the 
interest  of  the  employee. 

About  ten  years  ago  the  medical  examination  of  employees  became 
a  fixture  in  a  few  industries.  Gradually  it  became  apparent  that  for 
the  protection  of  the  old  working  force  and  for  the  new  workmen 
alike  the  examination  of  all  applicants  for  work  must  be  included  in 
this  system  of  health  supervision. 

Whereas,  ten  years  ago  only  three  or  four  industries  in  the  country 
had  established  some  system  of  health  supervision,  the  foundation 


RECLAIMING    THE    TUBERCULOUS    SOLDIER  465 

of  which  is  the  medical  examination  at  stated  intervals,  to-day  we 
see  a  very  comprehensive  and  thorough  system  in  operation  in  at 
least  one  hundred  industries  and  approximately  five  hundred  concerns 
have  inaugurated  some  health  system. 

It  is  impossible  to  estimate  the  results  of  the  work  of  these 
surgeons  upon  the  health  of  the  industrial  workers  of  the  land. 
Neither  can  we  say  to  what  extent  the  death  rate  from  both 
accidents  and  disease  has  been  reduced  by  their  efforts.  But  that 
the  results  have  been  immense  is  a  certainty. 

I  have  obtained  the  figures  from  ten  industries  where  the  best 
form  of  Industrial  Medicine  and  Surgery  is  practised,  where  the 
medical  examinations  are  thorough  and  complete  and  where  careful 
statistics  of  results  are  kept.  These  figures  show  that  last  year 
104,066  employees  were  given  medical  examinations;  that  during 
the  last  five  years  276,420  employees  have  been  examined  thoroughly. 
Some  of  these  industries  have  examined "  their  workers  only  during 
the  last  year,  while  others  have  had  the  system  in  force  for  the 
entire  five  years. 

During  these  five  years  examinations  have  resulted  in  the  dis- 
covery of  4423  cases  of  tuberculosis,  or  1.6  per  cent,  of  all  examined 
had  the  disease.  Approximately  one-third  of  these  were  cared  for 
by  the  industries  where  they  were  employed. 

With  a  hundred  industries  carrying  on  a  comprehensive  system 
of  Industrial  medicine  to-day  it  is  conceivable  that  during  the  next 
five  years  27,642,000  physical  examinations  of  employees  may  be 
made  and  442,300  cases  of  tuberculosis  discovered. 

If  the  states  will  only  provide  adequate  sanatoria  care  for  these 
cases,  the  greatest  advance  will  be  made  in  eradicating  this  greatest 
plague  of  humanity. 

The  Industrial  Surgeons'  Committee  of  the  Council  of  National 
Defense  has  proposed  a  program  for  the  complete  supervision  of  health 
of  the  industrial  army  during  this  crisis  through  which  the  nation 
is  now  passing.  Recognizing  that  the  industrial  army  is  of  equal 
importance  to  the  military  army  in  winning  the  war,  this  committee 
is  endeavoring  to  devote  its  energies  to  keeping  the  standard  of 
health  at  the  highest  level  among  all  workers  in  the  industries  neces- 
sary to  the  continuance  of  the  war  in  order  to  keep  production  up 
to  the  highest  mark. 

Healthful  workers  are  as  essential  to  production  as  the  most  effect- 
ive machinery — both  must  be  supervised.  To  attain  these  results 
the  committee  proposes  to  establish  in  all  industries  the  following 
program : 

1.  Supervision  of  physical  condition  of  employees  by  medical 
examinations. 

30 


466  INDUSTRIAL    MEDICINE    AND    SURGERY 

2.  Industrial  sanitation. 

3.  Sanitary  home  conditions. 

4.  Prevention  of  disease. 

5.  Prevention  of  accidents. 

6.  Early  and  proper  medical  and  surgical  treatment  when  needed. 
To  carry  out  this  program  the  industries  must  not  be  depleted  of 

physicians.  Other  medical  men  must  be  persuaded  to  enter  this 
field.  By  concentrating  upon  a  large  group  of  people  in  this 
way  the  doctors  can  supply  the  demands  of  the  civilian  population 
much  more  efficiently,  which  is  very  desirable  at  this  time  when  so 
many  of  our  profession  are  in  the  army. 

In  addition  to  this  force  of  physicians  the  committee  intends  to 
secure  the  greatest  co-operation  between  the  United  States  Public 
Health  Service,  the  Department  of  Labor,  the  state  and  municipal 
health  departments,  and  all  other  agencies  which  must  be  depended 
upon  to  do  a  part  of  this  great  work. 

It  is  hoped,  and  there  is  reason  to  believe,  that  the  federal  govern- 
ment will  throw  its  influence  behind  this  movement  in  order  to  have 
the  war  industries  at  least  adopt  this  program.  This  is  one  of  the 
greatest  war  measures  that  has  been  undertaken  during  this  national 
emergency. 

With  such  a  system  of  health  supervision  established  in  industries 
throughout  the  country,  millions  of  people  will  be  given  periodical 
medical  examinations  and  thousands  of  cases  of  known  and  unknown 
tuberculosis  will  be  found.  Experience  in  this  line  of  work  has  proven 
that  over  85  per  cent,  of  these  cases  will  still  be  in  the  curable  stages. 

What  will  become  of  these  tuberculous  Industrial  Soldiers?  How 
will  the  civilian  forces  handle  them?  What  provisions  have  the  states 
made  to  adequately  treat  these  cases?  How  will  the  Federal  Govern- 
ment meet  the  problem? 

By  co-operation  and  co-ordination  the  medical  department  of 
the  army  and  the  various  civilian  agencies  can  meet  this  situation. 
God  grant  that  we  may  arise  to  our  opportunity! 

The  immediate  problems  for  the  civilian  forces  are: 

1.  Providing  in  every  state  several  sanatoria  where  these  cases 
can  be  treated. 

2.  Laws    making    sanatorium    treatment    compulsory    until    the 
disease  is  arrested. 

3.  Co-operation  with  the  Industrial  program  in  order  to  discover 
the  tuberculous  employees. 

'  4.  Co-operation  with  the  machinery  of  the  army  to  have  the  tuber- 
culous draftee  referred  to  the  proper  civilian  authority. 
5.  A  National  program  of  Health  Supervision  carried  on  along 
lines   similar   to   the    Food    Conservation   work,    whereby  the 


EECLAIMING    THE    TUBERCULOUS    SOLDIER  467 

entire  population  of  the  country  would  be  induced  to  enter  into 
a  great,  common-sense  health  movement,  as  a  patriotic  duty. 
This  could  be  accomplished  by  an  educational  campaign  which 
has  the  moral  and  financial  backing  of  the  Federal  government. 
The  medical  examination  of  everybody  could  be  made  a  fact, 
and  the  correction  of  the  diseased  conditions  would  naturally 
follow. 
The  present  tuberculosis  problem  has  been  facing  the   medical 
department  of  the  army  for  over  a  year  now.     Those  found  at  the 
draft  examination  with  this  disease  and  even  many  of  those  discovered 
within  three  months  after  induction  into  the  service  have  been  thrown 
back  into  civilian  life.     Unfortunately  only  those  cases  which  were 
found  at  the  examination  at  the  cantonments  were  referred  to  civil- 
ian authorities.     Some  of  the  states  have  provided  for  the  care  of 
these  but  others  have  failed  to  meet  the  problem. 

The  first  great  advance  in  the  army  program  was  made  the  first 
of  this  year  (1918)  when  the  Surgeon-General  issued  an  order  that  all 
cases  of  tuberculosis  found  at  the  cantonments  after  the  men  had  been 
inducted  into  the  service  would  hereafter  be  considered  "in  line  of 
duty." 

This  stopped  the  discharge  of  many  of  these  cases.  Sanatoria 
treatment  was  offered  to  all  regardless  of  "line  of  duty"  or  not,  but 
refusal  to  accept  it  meant  their  discharge.  For  those  in  line  of  duty 
the  War  Risk  Insurance  Bureau  took  up  the  case  and  arranged  for 
compensation.  The  treatment  was  left  to  the  individual's  desires 
and  arrangements.  Any  of  these  line  of  duty  cases  could  apply  for 
treatment  in  one  of  the  army  sanatoria  if  they  so  desired.  This  was 
not  generally  known  by  the  men,  however,  and  the  busy  army  doc- 
tors did  not  always  take  the  opportunity  of  urging  sanatorium  treat- 
ment to  them.  In  1918  the  War  Risk  Insurance  Bureau  through 
the  United  States  Public  Health  Service  arranged  for  sanatorium  care 
for  many  of  these  discharged  cases. 

About  nine  months  ago  (August,  1917),  the  Division  of  Physical 
Reconstruction  and  Rehabilitation  of  Disabled  Soldiers  was  organized 
in  the  Surgeon-General's  Office.  The  purpose  of  this  Division  was 
to  provide  the  machinery  for  completing  the  cure  of  certain  types  of 
disabled  soldiers  returning  from  overseas  and  arranging  for  their 
re-education  and  vocational  training  when  it  was  necessary  for  them 
to  learn  a  new  occupation  because  of  the  nature  of  their  disability. 

At  first  it  was  thought  this  work  would  be  limited  largely  to  the 
surgical  cases,  especially  orthopedic  and  severe  facial  disfigurements. 
Gradually  the  plans  for  Physical  Reconstruction  have  unfolded, 
however,  until  to-day  it  includes  every  type  of  medical  or  surgical 
case  requiring  prolonged  treatment,  and  instead,  of  referring  only  to 


468  INDUSTKIAL    MEDICINE    AND    SURGERY 

the  disabled  from  overseas,  all  cases  in  this  country  or  from  the  expe- 
ditionary forces  abroad  are  included  in  its  scope.  It  is  realized  now 
that  the  tuberculous  patients  will  make  up  a  large  proportion  of  those 
needing  reconstruction  and  in  many  instances  vocational  retraining. 

In  December,  1917,  and  again  in  January,  1918,  a  new  policy  was 
submitted  by  the  Surgeon-General  to  the  Secretary  of  War  for  his 
approval.  The  Army  Regulations  provided  that  when  a  soldier  was 
unfit  for  full  military  service  he  was  to  be  discharged  from  the  Army. 
Medical  and  surgical  treatment  was  rendered  to  these  men  but  often 
they  were  discharged  before  a  cure  had  been  accomplished. 

This  new  policy,  however,  provided  that  in  the  future  no  disabled 
soldier  should  be  discharged  from  the  Army  until  from  a  physical,  func- 
tional and  mental  standpoint  he  had  been  cured  as  far  as  it  was  humanly 
possible.  It  further  provided  that  the  medical  department  of  the 
army  should  employ  all  therapeutic  adjuncts  necessary  to  attain  such 
a  result,  including  physiotherapy,  bedside  occupations,  and  cm-ative 
therapy  in  workshops. 

This  policy  was  approved  by  the  Secretary  of  War  the  first  of  May, 
1918. 

This  will  prove  to  be  one  of  the  greatest  advances  ever  made  by 
the  medical  department  of  the  army  and  is  another  notable  achieve- 
ment of  our  illustrious  chief.  General  Gorgas.  The  far  reaching  re- 
sults of  such  a  policy  are  only  vaguely  comprehended  by  the  majority 
of  men  as  yet.  It  means  the  death  knell  of  our  old  soldiers'  homes 
where  disabled  men  in  the  past  have  been  prematurely  relegated  to 
the  scrap  heap. 

To  complete  this  process  of  reclaiming  the  disabled  soldiers  Con- 
gress is  providing  the  machinery  for  their  vocational  retraining  when 
necessary,  assistance  to*  complete  their  educations,  replacing  in  occu- 
pations where  they  will  have  as  great  or  a  greater  earning  capacity 
than  before  they  were  handicapped  and  the  proper  soc  al  and  eco- 
nomic supervision  to  see  that  their  rehabiHtation  is  completed  and  so 
remains.  This  portion  of  the  work  will  undoubtedly  be  delegated 
to  the  Federal  Board  for  Vocational  Education  after  the  man  is  dis- 
charged from  the  army.  Co-operation  between  this  civilian  agency 
and  the  medical  department  of  the  army  will  enable  much  of  this 
vocational  training  to  begin  during  the  final  stages  of  the  man's 
convalescence. 

Already  the  War  Risk  Insurance  Act  has  been  placed  in  operation 
and  it  provides  excellent  compensation  for  these  men — a  compen- 
sation based  upon  a  debt  which  the  nation  rightfully  owes  her  dis- 
abled soldiers  and  not  given  to  them  as  a  charity.  No  matter  how 
proficient  these  men  become  as  the  result  of  vocational  training,  this 
compensation  will  not  be  reduced. 


RECLAIMING  THE  TUBERCULOUS  SOLDIER         469 

The  tuberculous  soldier  is  included  in  this  far  reaching  plan  as  well 
as  all  other  types  of  disabilities.  Sanatoria  are  being  established  in 
various  parts  of  the  country  where  these  tuberculous  soldiers  can  be 
sent  and  retained  until  cured.  The  order  has  already  gone  forth  mak- 
ing it  compulsory  to  send  all  cases  of  tuberculosis  to  these  sanatoria, 
both  from  the  home  and  expeditionary  forces  before  they  are  dis- 
charged. Some  will  demand  their  discharge  on  arriving  at  the  sana- 
torium and  will  bring  political  influence  to  bear  to  secure  it.  But 
the  majority  will  be  subtly  persuaded  to  remain  until  their  disease 
is  apparently  cured.  The  prolonged  course  of  treatment  necessary 
for  these  men  will  enable  many  of  them  to  be  vocationally  trained 
for  better  positions  in  life  before  they  are  discharged. 

Now  that  the  army  has  provided  this  improved  arrangement  for 
the  tuberculous  soldier  it  behooves  the  civilian  forces  to  make  equally 
elaborate  preparations  for  the  physical  reconstruction  and  rehabili- 
tation of  the  tuberculous  industrial  soldier  and  in  fact  for  all  civiHan 
tuberculous  patients.  This  can  only  be  accomplished  by  federal  and 
state  provisions  for  the  discovery  of  these  patients  and  the  necessary 
sanatoria  for  their  treatment.  Combined  with  this  must  be  a  nation- 
wide educational  campaign  to  arouse  public  opinion  in  favor  of  such 
a  program. 

The  treatment  of  both  the  military  and  civilian  tuberculous  should 
be  for  the  combined  purpose  of  accomplishing  their  complete  physical 
and  mental  cure.  Instead  of  returning  them  to  their  communities 
as  hospitalized  individuals  they  should  be  returned  as  more  useful 
economic  units  of  society.  This  can  be  attained  by  introducing 
curative  work  and  vocational  training  into  the  routine  sanatorium 
treatment. 

The  following  outline  is  a  suggested  plan  for  the  physical  recon- 
struction and  rehabilitation  of  the  tuberculous  from  both  the  mili- 
tary and  industrial  armies. 

In  reclaiming  those  in  the  military  and  industrial  armies  who  have 
contracted  tuberculosis  and  in  securing  their  complete  rehabilitation, 
the  following  requirements  must  be  considered : 

I.  The  best  medical  treatment  with  certain  adjuncts  to  secure 
the  most  rapid  recovery. 

II.  Certain  occupations  in  connection  with  this  treatment,  to 
prevent  hospitalization  and  to  refit  for  employment. 

III.  Suitable  employment  after  the  disease  is  arrested  or  apparently 
cured,  combined  with  proper  medical  supervision 

I.  The  best  medical  treatment  with  certain  adjuncts  to  secure  the 
most  rapid  recovery. 
A.  Prevention. 

1.  By    periodical    physical    examination    to    discover    early 
signs  of  the  threatened  disease. 


470  INDUSTRIAL    MEDICINE    AND    SURGERY 

2.  By  prompt  and  proper  medical  care  of  all  colds,  grippe, 
bronchitis,  pneumonia,  and  other  respiratory  diseases. 

3.  By  proper  care  of  certain  complications  predisposing  to 
tuberculosis  which  remain  after  these  act  ve  diseases 
are  cured.  For  instance,  pleurisy  following  grippe  and 
pneumonia,  or  the  small  patches  of  unresolved  pneumonia 
following  the  latter  disease  predispose  to  tuberculosis. 

B.  Sanatoria  Care,  Medical  Treatment  and  Adjuncts. 

1.  When  tuberculosis  develops,  the  case  should  be  sent  to 
a  sanatorium  at  once. 

2.  The  medical  care  should  be  under  specialists  in  tuber- 
culosis work. 

3.  During  the  active  stage  when  temperature,  weakness, 
and  aggravated  symptoms  demand  absolute  rest  in  bed, 
the  men  should  be  entertained,  but  all  mental  and  physical 
work  should  be  barred. 

4.  Light  mental  and  physical  work  can  become  an  adjunct 
to  the  medical  treatment  when  the  patient  reaches  the 
stage  of  treatment  which  permits  his  sitting  up  in  bed 
or  spending  a  few  hours  in  a  reclining  chair  on  the  porch. 
a.  Purposes:  * 

1.  To  stimulate  hope  and  desire  for  recovery. 

2.  To  occupy  patient's  mind,  to  remove  his  thoughts 
from  his  disease,  and  all  outside  worries.  Encom- 
aging  reports  from  home  that  his  family  is  all  right 
and  being  properly  cared  for  are  essential  to  help 
put  patient  in  proper  mental  attitude. 

3.  To  gradually  prepare  him  for  a  more  elaborate  course 
of   study  and  work  as  soon  as  his  condition  warrants. 

h.  Types  of  Mental  and  Physical  Work: 

1.  These  must  be  arranged  after  a  careful  study  of  each 
individual  with  a  view  of  accomplishing  the  purpose 
desired. 

2.  The  studies  should  be  arranged  along  the  Knes  of  the 
man's  former  occupation,  with  the  idea  of  making 
him  a  better  employee  or  employer.  For  instance, 
if  a  farmer,  his  studies  should  be  along  the  Knes 
of  agriculture.  If  he  were  a  dry  goods  clerk,  his 
studies  should  be  the  "textile  industries,"  the 
''manufacture  of  silks  and  dress  goods, "" business 
management,"  "human  engineering,"  etc. 

3.  Most  cured  tuberculous  cases  can  return  to  their 
former  occupations,  except  those  employed  in  dusty 
work,  as  coal  miners,  certain  types  of  packers,  etc.; 


RECLAIMING  THE  TUBERCULOUS  SOLDIER        471 

in  occupations  with  disease  hazards,  as  lead  workers, 
phosphorus  workers,  etc.;  in  jobs  with  great  ex- 
posure to  elements,  combined  with  heavy  work, 
as  teamsters.  For  these  there  must  he  training  in 
new  occupations.  Here  again  the  individual  equa- 
tion must  be  carefully  studied.  After  the  man 
has  decided  what  line  of  work  he  intends  to  follow, 
his  studies  should  be  along  that  line. 

4.  Light  occupations  should  be  provided  for  these  bed 
and  chair  patients  as  soon  as  their  conditions 
warrant.  (1)  Embroidery,  pottery,  light  jewelry, 
and  the  usual  arts  and  crafts  work  commonly 
employed  heretofore  are  not  practical  nor  .appeal- 
ing to  the  average  man.  They  may  well  be  used 
for  the  female  patients.  (2)  Curative  work  should 
always    be  made  of  the  most  practical  character. 

5.  Examples  of  light  work : 

(a)  Knitting  socks,  wristlets,  sweaters,  etc.,  not  by 

hand,  but   on   the  light  machines   now  provided 

for  this  purpose. 
(6)  Making  dressings  for  hospitals. 
(c)   Making  various  kinds  of  splints. 
{d)  Wrapping     armatures.     Arrangements     can     be 

made  with  nearby  electrical  concerns  to  have  this 

done  by  piece-work. 
(e)  Sign  painting. 

(/)  Typewriting  and  learning  shorthand. 
ig)  Toy  making  by  hand. 
{h)  Book  binding 
(^)    Careful  analysis  of  light  occupations  will  reveal 

many  more  with  a  practical  trend. 

6.  Moving  pictures,  lectures,  and  other  forms  of  enter- 
tainment, both  amusing  and  instructive,  must  be 
combined  with  this  medical,  mental  and  occupa- 
tional therapy,  as  a  definite  part  of  the  cure. 

II.  Various  studies,  heavier  and  more  continuous  occupations,  and 
retraining  for  work. 

After  the  patient's  disease  becomes  quiescent  and  his  temperature 
remains  normal,  and  his  strength  returns;  and  in  the  opinion  of  the 
physician  the  patient  can  have  a  certain  number  of  hours  of  exercise 
per  day,  his  course  of  study  can  be  increased  and  he  can  be  permitted 
to  do  heavier  work. 

When  necessary  to  retrain  for  new  occupations,  this  can  now  begin. 

The  doctor  must  at  all  times  decide  the  number  of  hours  of  study 


472  INDUSTRIAL    MEDICINE    AND    SURGERY 

and  work  which  it  is  advisable  for  the  patient  to  pursue.     This  must 
be  increased  and  decreased  according  to  the  patient's  daily  condition. 

A.  Purposes: 

1.  Same  as  purposes  for  Hghter  occupations  and  study,  plus. 

2.  To  prevent  laziness,  dependence,  and  hospitalization  so 
prevalent  in  all  sanatorium  treatment. 

3.  To  refit  for  employment  in  his  old  or  a  better  posi- 
tion than  he  had  previous  to  the  war. 

4.  To  increase  productivity  and  earning  capacity. 

B.  Types  of  Study  and  Work: 

1.  His  studies  started  during  his  earlier  days  can  be  con- 
tinued, increased,  and  supplemented  by  classroom  work 
and  by  special  lectures  and  note-taking. 

Lectures  in  almost  any  line  of  study  can  be  procured 
gratis  from  our  large  industrial  establishments. 

2.  His  work  can  now  be  increased  to  give  productivity  and 
wages;  and  thus  develop  a  sense  of  independence  and 
usefulness. 

3.  Examples  of  occupations: 
a.  Carpentry. 

h.  Mechanics — especially  acetylene  welding,  lighter  motor 
mechanics,  inspector  work,  as  of  small  shells,  and  other 
lines,  especially  valuable  for  war  industries. 

c.  Agriculture — bee  husbandry,  poultry  raising,  stock  rais- 
ing, gardening,  and  lines  suitable  to  those  who  were 
farmers  and  to  the  few  suitable  cases  who  will  be  re- 
trained for  farming. 

Every  sanatorium  should  have  its  own  poultry  yards, 
bee  hives,  and  dairy,  and  these  can  be  utilized  for 
teaching  purposes. 

d.  Tailoring — this  work  is  especially  fitted  as  a  form  of 
occupation  for  the  tuberculous  when  he  can  first  begin 
to  return  to  work.  It  is  not  heavy,  can  be  performed 
in  airy  rooms,  is  done  by  machines,  for  the  most  part 
easily  manipulated,  and  pays  good  wages.  Every 
sanatorium  could  make  suits  and  uniforms  for  our 
soldiers  and  sailors,  such  as  are  being  made  by  the 
factory  in  New  York  which  is  run  by  150  arrested 

"  tuberculous  cases. 

e.  Shoe  repairing:  Old  shoes  from  the  army  could  be  sent 
here  for  repair,  which  would  give  productivity  and 
wages. 

/.   Commercial  work  should  be  provided. 

g.  Every  occupation  represented  by  a  patient  should  be 


RECLAIMING  THE  TUBERCULOUS  SOLDIER        473 

represented  in  some  way  at  the  sanatorium  to  improve 
the  patient  along  his  line  of  work. 
h.  The  idea  that   all  tuberculous   cases  after  leaving   a 
sanatorium  must  return  only  to  outside  work  is  er- 
roneous.    With  very  few  exceptions  they  can  return 
to  their  old  employment.     Therefore,  our  idea  should  be 
to  improve  their  condition  by  education,  by  a  broader 
insight  into  their  work,  and  fitting  them  to  advance 
into  better  positions. 
III.  Suitable  employment  after  the  disease  is  arrested  or  apparently 
cured  combined  with  proper  medical  supervision. 

A.  No  tuberculous  patient  should  be  discharged  from  a  sana- 
torium until  the  disease  is  arrested  or  apparently  cured. 
In  some  cases  this  may  mean  two  years  or  more  of  sana- 
torium treatment.  However,  if  he  is  discharged  before 
this  goal  is  obtained,  the  benefit  of  his  sanatorium  treatment 
may  be  lost.  Exceptions  may  have  to  be  made  to  this  rule, 
but  as  a  general  principle  this  standard  should  be  adhered 
to.  In  some  cases  arrangements  for  suitable  work  under 
medical  supervision  can  be  made,  thus  allowing  the  cure  to 
continue  while  the  patient  is  earning  part  or  all  of  his  liv- 
ing. State  industries  should  be  established  for  this  purpose 
in  connection  with  state  sanatoria. 

B.  These  men  should  be  placed  at  work  under  the  best  sanitary 
conditions  possible.  If  their  old  jobs  were  in  unsanitary 
plants,  sweat-shops,  etc.,  similar  jobs  should  be  secured 
for  them  in  suitable  working  places. 

C.  Definite  arrangements  should  be  made  whereby  these 
patients  will  have  medical  supervision  and  periodical  ex- 
aminations, in  order  to  make  sure  that  their  disease  remains 
arrested  and  continues  into  a  permanent  cure. 

The  effective  plans  for  the  salvaging  of  the  tuberculous  from  the 
military  army  should  awaken  us  to  the  immediate  need  of  reclaiming 
the  tuberculous  from  the  industrial  army  and  from  the  entire  civilian 
population.  If  we  arise  to  our  obligation  and  strive  to  conserve  our 
manpower  in  this  period  of  national  emergency,  the  result  will  be  one 
of  the  greatest  and  most  beneficial  by-products  of  this  terrible  war. 


Part   IV 
INDUSTRIAL  SURGERY 

CHAPTER  XXXI 

THE  SURGICAL  DISPENSARY,  STAFF  AND  EQUIP- 
MENT; PREVENTIVE  SURGERY 

The  physician  engaged  in  accident  surgery  for  an  industry  is 
naturally  trained,  by  the  very  character  of  the  work,  to  view  every 
case  from  its  economic  standpoint.  An  accident  occurs,  and  at  once 
he  plans  the  subsequent  treatment  with  four  fundamental  principles 
in  mind: 

1.  How  to  aid  recovery  the  quickest. 

2.  How  to  prevent  permanent  disability. 

3.  How  to  avoid  a  fatal  termination  of  the  case. 

4.  How  to  prevent  a  recurrence  of  the  accident. 

The  welfare  of  the  patient,  the  protection  of  the  other  employees, 
and  the  interests  of  the  employer,  all  demand  the  careful  con- 
sideration of  these  principles. 

Unfortunately  such  a  conception  of  accident  surgery  did  not 
obtain  until  of  recent  years.  Like  the  man  in  Robert  Burdette's 
lecture,  "Acres  of  Diamonds,"  our  best  surgeons  were  seeking  the 
newer  and  rarer  conditions  in  other  fields  while  the  real,  constructive 
surgery,  ever  present  in  their  midst,  as  the  result  of  accidents,  was 
more  or  less  neglected. 

But  more  and  more  during  the  last  ten  years  expert  surgeons  have 
been  attracted  to  this  field  of  industrial  surgery  and  their  writings 
and  teachings  are  awakening  the  profession  to  its  duty  in  regard  to  the 
careful  treatment  of  the  victims  of  accidents.  With  the  enactment 
of  compensation  laws  greater  demands  have  been  placed  on  the  sm-geon 
by  industry,  by  the  employees,  and  by  the  legal  profession.  He  is 
frequently  forced  to  give  a  prognosis  of  the  expected  results  and 
occasionally  the  line  of  treatment  adopted  by  him  is  reviewed  and 
criticised  by  others  before  the  compensation  board.  Not  only  must 
the  injured  part  be  cured,  but  it  must  be  functionally  restored  so 
that  the  patient  can  again  become  a  productive  unit.     If  such  a  result 

475 


476  INDUSTRIAL    MEDICINE    AND    SURGERY 

is  not  obtained,  then  a  very  definite  reason  for  the  failure  is  often 
demanded  by  these  lay  forces. 

These  facts  have  caused  all  surgeons,  and  especially  those  engaged 
in  industrial  surgery,  to  recognize  more  fully  their  responsibility  toward 
the  accident  cases.  They  are  thinking  less  of  the  surgical  end-result 
and  more  in  terms  of  the  economic  end-result. 

Industrial  surgery  consists  in  the  prevention  and  treatment  of  all 
injuries,  the  result  of  accidents,  arising  in  the  course  of  employment. 
These  are  usually  divided  into  minor  and  major  accidents.  The 
subject  can  best  be  treated  under  the  subheads  of:  (1)  Preventive 
Surgery;  (2)  First  Aid;  (3)  Emergency  Treatment;  (4)  Subsequent  or 
Permanent  Treatment. 

Before  entering  into  a  discussion  of  these  subheads,  consideration 
should  be  given  to  the  necessary  arrangements  for  the  proper  care 
of  accident  cases  in  industry. 

The  Surgical  Staff. — Industrial  surgery,  in  its  best,  most  complete 
interpretation,  is  now  based  on  the  principle  of  bringing  the  surgeon 
to  the  injured  instead  of  the  injured  to  the  surgeon.  In  other  words 
the  surgeon  must  be  constantly  on  the  job  in  industry  to  render 
immediate  and  proper  treatment  to  all  injured  employees.  This 
principle  is  the  greatest  advance  which  has  been  made  in  accident 
surgery  during  the  last  decade.  Moorhead,  Corwin,  Clark,  Hudson, 
Farnum,  Mock,  and  other  surgeons  in  industry,  and  Bloodgood, 
Edward  Martin  and  others,  have  emphasized  this  point  at  every 
opportunity. 

For  adequate  treatment  of  injured  employees  every  industry 
should  provide  the  services  of  a  qualified  surgeon.  The  smaller  plants 
cannot  perhaps  afford  to  keep  a  surgeon  on  the  premises  at  all  times 
and  the  best  plan  for  them,  therefore,  is  to  combine  with  others  for  the 
employment  of  a  surgeon.  A  central  office  in  the  neighborhood  of 
several  industries,  at  which  a  surgeon  is  always  in  attendance,  affords 
the  best  solution  for  these  smaller  concerns.  Well  trained  assistants 
must  be  instructed  to  render  the  necessary  first  aid  care. 

The  large  industry,  especially  if  accidents  are  frequent,  should 
have  a  surgeon  near  at  hand  at  all  times  so  that  prompt  care  can  be 
rendered.     Three  plans  may  be  adopted  to  meet  the  situation,  namely : 

1.  The  doctor  should  spend  a  part  of  each  day  at  the  plant  dressing 
the  minor  cases  which  report  to  the  doctor's  office,  and  caring  for  the 
injuries  that  may  arise  during  this  period.  After  two  or  three  hours  he 
leaves  the  plant  to  visit  the  major  accident  cases  in  their  homes  or  at 
the  hospital.  He  may  care  for  the  injured  employees  in  one  or  two 
other  plants  by  a  similar  arrangement.  He  must  keep  the  plant 
posted  at  all  times  concerning  his  whereabouts.  An  associate  must 
be  arranged  for  who  can  respond  to  an  emergency  call  when  he  cannot. 


THE    SURGICAL    DISPENSARY    STAFF  477 

During  his  absence  from  the  plant  a  well  trained  first  aid  man,  or 
preferably  a  nurse,  should  be  in  attendance  to  render  emergency  care 
to  any  injured.  This  person  must  develop  clear  judgment  as  to  when 
to  call  the  surgeon  or  when  to  send  an  employee  to  his  office,  or  to  the 
hospital,  to  see  him. 

This  plan  is  in  force  in  many  industries  and  gives  fair  results.  It 
is  indeed,  a  great  improvement  over  the  old  method  of  leaving  an 
injured  employee  without  any  care  until  some  doctor — any  doctor — 
could  be  summoned,  or  until  the  ambulance  could  be  called  and  the 
injured  party  sent  to  the  hospital. 

2.  The  second  plan  consists  of  employing  an  all  time  physician  who 
remains  constantly  at  the  plant  during  working  hours  giving  immedi- 
ate emergency  treatment  to  all  injured  employees  and  attending  to 
the  daily  dressings  of  the  ambulatory  cases.  The  major  accident  cases 
are  sent  to  the  hospital  or  to  their  homes  under  the  care  of  some  other 
surgeon.  Usually  the  management  arranges  with  this  surgeon  to 
treat  these  major  cases,  which  is  preferable,  or  the  injured  employee, 
or  his  family,  chooses  the  doctor  he  desires. 

As  a  rule  such  company  surgeons  become  expert  at  emergency  care 
but  are  not  qualified  to  carry  the  treatment  of  serious  injuries  through 
to  their  completion. 

This  plan  has  been  in  vogue  in  many  of  our  large  industries  for 
years.  It  has  given  good  results  but  not  the  results  obtained  by  plac- 
ing the  full  responsibility  for  the  best  and  quickest  possible  cure  on  the 
surgeon  connected  with  the  industry. 

3.  The  third  plan  is  more  often  found  in  those  plants  employing 
part  time  surgeons  but  it  is  also  applicable,  and  in  use,  among  the  full 
time  surgical  staffs  when  two  or  more  doctors  are  employed.  One 
physician,  the  surgical  assistant,  is  thoroughly  trained  in  emergency 
treatment  and  the  subsequent  dressings  of  all  injured  employees 
reporting  to  the  plant  dispensary.  The  chief  surgeon  spends  a  part 
of  his  time  at  the  plant  supervising  the  emergency  work,  as  well  as  all 
the  other  angles  of  the  industrial  medical  practices.  The  remainder  of 
his  time  is  spent  at  the  hospital  and  at  the  homes  of  injured  employees 
rendering  the  necessary  permanent  treatment. 

In  the  part  time  staff  such  a  surgeon  usually  has  time  to  teach  and 
develop  a  private  practice.  He  has  two  surgical  assistants  each 
spending  a  half  day  at  the  plant.  I  always  insist  on  one  of  these  living 
near  the  plant  so  that  he  can  quickly  be  called  at  night  in  case  of  an 
accident.  Where  a  large  night  force  is  employed  a  surgeon  should  be 
on  the  job  all  night. 

This  third  plan,  involving  as  it  does  the  combination  of  an  experi- 
enced emergency  surgeon  at  the  plant  at  all  times,  and  the  supervision 
of  all  the  work  and  the  permanent  care  of  the  major  accidents  by 


478 


INDUSTRIAL    MEDICINE    AND    SURGERY 


another  qualified  surgeon,  has  given  the  best  possible  results  in  indus- 
trial surgery. 

Every  industry  employing  men  or  women  in  work  where  accidents 
are  prone  to  occur  should  adopt  one  of  these  systems.  The  best  plan 
necessitates  the  employment  of  good  surgeons  at  all  times.  Cheap 
surgery  usually  gives  poor  results.  Employers  will  find  that  expert 
surgery,  while  costing  more  in  the  beginning,  is  by  far  the  cheapest 
method  in  the  long  run.  Such  surgery  will  reduce  law  suits,  lessen 
compensation,  and  add  greatly  to  the  loyalty  and  confidence  of  the 
employees. 

Surgeons  employed  by  industry  must  become  thoroughly  imbued 
with  the  fact  that  proper  treatment  rendered  immediately  after  an 


Fig.   69. — Surgical  room  for  men.      (From  Doctor's  Office,  Sears,  Roebuck  &  Co.) 


accident  occurs  is  one  of  the  greatest  principles  of  preventive  surgery, 
surpassed  only  by  the  prevention  of  accidents.  They  must  study  the 
local  situation  so  that  someone  absolutely  qualified  to  give  this  imme- 
diate treatment  is  always  close  at  hand.  Theirs  is  one  of  the  most 
responsible  positions  in  the  medical  profession. 

The  surgical  nurse  is  the  most  valuable  assistant  the  surgeon  in 
industry  can  have.  Some  employ  a  male  nurse  for  this  position  but 
I  have  found  a  well  trained,  carefully  uniformed  female  nurse  is  a  more 
efficient  assistant.  Her  presence,  if  she  is  adept,  conscientious  and 
tactful,  adds  to  the  confidence  of  the  employees  and  increases  the 
morale  among  them  when  they  visit  the  office. 

This  nurse  should  remain  in  the  plant  dispensary  continuously 
during  the  working  hours.  She  should  be  thoroughly  trained  in  her 
relations  to  emergency  surgery  and  able  to  take  charge  of  a  case  and 
render  first  aid  care  until  the  surgeon  arrives  if  he  should  be  absent 
from  the  plant.     Such  nurses  become  quite  skilled  in  this  work  and 


THE    SURGICAL    DISPENSARY    STAFF  479 

undoubtedly  have  saved  the  hves  of  employees  in  more  than  one 
serious  case. 

The  nurse  sterilizes  the  dressings  and  keeps  a  supply  on  hand  at  all 
times.  She  keeps  the  instruments  sterilized  and  ready  for  immediate 
use.  She  prepares  the  patients  for  minor  operations  performed  in  the 
plant  dispensary  and  assists  at  these  operations.  In  fact  she  is  a 
versatile  operating  room  nurse  and  surgical  dispensary  nurse  combined. 

In  one  plant  dispensary  where  an  average  of  one  hundred  injured 
employees  received  emergency  treatment  or  reported  for  subsequent 
dressings  daily  between  the  hours  of  8  a.m.  and  12  noon,  one  emer- 
gency surgeon  and  two  surgical  nurses  were  able  to  efficiently  handle 
this  work.  Miss  Mabel  Liddel,  one  of  the  pioneer  industrial  surgical 
nurses  of  the  country,  was  largely  responsible  for  developing  this 
system. 

Just  outside  the  surgical  room  a  girl  clerk  was  stationed.  As 
the  employees  left  she  collected  their  passes  and  recorded  on  their 
permanent  records  the  penciled  notations  made  on  the  passes.  His- 
tories of  new  accidents  were  obtained  and  recorded  in  the  same  way. 
The  doctor  questioned  every  new  accident  case  carefully  and  brought 
out  all  important  points  which  would  help  in  preventing  the  recurrence 
of  a  similar  accident.     (See  Chapter  12  for  records  of  Accident  Cases.) 

This  clerk  kept  a  tickler  system  on  each  employee  and  if  he  failed 
to  report  promptly  at  the  designated  hour  for,  his  dressing  would 
phone  to  the  department  and  have  him  sent  to  the  office.  Occasion- 
ally it  happened  that  an  employee  remained  at  home  because  of  his 
injury  without  notifying  his  department  or  the  doctor.  This  tickler 
system  enabled  the  detection  of  all  such  cases.  One  of  the  surgical 
nurses  would  call  on  the  absent  employee  in  the  afternoon  and  either 
bring  him  to  the  office  for  treatment  or  would  summon  the  surgeon 
to  his  home.  This  constant  watchfulness  is  necessary  to  prevent 
complications  developing  in  these  accident  cases,  as  employees  are 
frequently  careless  about  their  dressings  or  prefer  to  try  some  home 
remedy,  as  a  bread  and  milk  poultice,  thus  adding  greatly  to  the 
danger  of  infections. 

The  Surgical  Office. — Every  plant  of  sufficient  size  to  warrant 
a  doctor's  office  should  set  aside  one  room  for  the  surgical  cases. 
It  is  unsightly,  arousing  fears  in  the  employees,  if  the  sick  and  those 
reporting  for  examinations  must  witness  the  dressings  of  the  injured. 
Furthermore  such  an  office  should  be  kept  as  clean  and  as  aseptic  as 
any  operating  room.  This  is  often  difiicult  where  workmen  must 
report  in  their  dirty,  greasy  working  clothes,  but  nevertheless  clean- 
liness can  be  maintained  even  under  these  conditions. 

Where  women  are  employed  a  separate  surgical  room  should  be 
provided  for  them,   or   if  only  one  room  is  available,  men  should 


480 


INDUSTRIAL   MEDICINE    AND    SURGERY 


be  barred  while  an  injured  woman  employee  is  receiving  her  dressing, 
even  though  it  is  only  an  injured  finger.  As  much  segregation  of 
the  sexes  in  the  doctor's  office  must  be  maintained  as  possible. 
The  more  nearly  conditions  can  be  made  to  correspond  to  a  well 
regulated  private  office  the  better,  for  only  in  this  way  can  the  absolute 
confidence  of  the  employees  be  secured. 

The  office  should  be  well  lighted,  well  ventilated,  and  kept  as 
free  from  drug  and  wound  odors  as  possible.  The  walls  should  be 
white  enameled  and  the  floors  made  preferably  of  tile  or  of  one  of  the 
cement-like  preparations  so  commonly  used  in  hospitals.  Cracks  and 
other  places  where  dust  can  collect  must  be  obliterated.  The  furni- 
ture and  equipment  should  be  of  white  enamel. 


Fig.  70. — Surgical  dressing  room  for  women. 


Instruments,  especially  knives  and  other  terrifying  paraphernalia, 
should  be  kept  out  of  sight.  The  same  is  true  of  bloody  or  pus- 
saturated  dressings  which  hav,e  been  removed.  These  should  be  thrown 
in  a  can  covered  with  a  lid  which  can  be  raised  by  a  foot  pedal.  When 
a  wound,  which  may  appear  frightful  to  others  is  to  be  dressed  the 
office  should  be  cleared  of  all  other  patients.  Too  much  attention  can- 
not be  paid  to  these  details  which,  if  not  observed,  tend  to  have  a  bad 
reaction  on  the  employees. 

The  equipment  of  this  office  should  be  simple  but  adequate.  The 
various  illustrations  show  the  ideal  arrangement  in  some  surgical 
dispensaries  in  industry.     It  should  consist  of: 

1.  A  stationary  wash  stand  with  hot  and  cold  water  faucets  with 
a  foot  pedal  control. 

2.  A  stationary  foot  tub  and  another  for  hand  or  arm  baths. 
These  facilitate  the  work  greatly  as  many  cases  will  need  a  prolonged 
hot  bath  for  some  sprain  or  chronic  infected  part. 


THE    StTRGICAL    DISPENSARY    STAFF  481 

3.  At  least  two  basins  in  a  rack  should  be  provided  for  hand  solu- 
tions for  the  use  of  the  surgeon. 

4.  One  or  more  white  enameled  chairs,  depending  on  the  size  of 
the  room  and   number  of   patients   accommodated   at   one    time. 

5.  One  white  enameled  stool  on  which  the  patient  can  sit  while  he 
rests  his  arm  on  a  table  for  hand  dressings. 

6.  One  or  more  white  enameled  foot  stools  of  sufficient  height  to 
facilitate  foot  dressings. 

7.  One  white  enameled  surgical  table  for  the  patients  who  must 
lie  down  for  treatment.  This  table  will  often  be  used  for  patients 
showing  signs  of  fainting. 

8.  One  recHning  chair,  somewhat  similar  to  a  dentist's  chair,  for 
use  in  eye  injuries,  especially  in  removing  foreign  bodies  from  the  eye. 

9.  One  small  dressing  table  for  use  in  hand  and  arm  cases. 

10.  One  white  enameled,  glass  topped  table  on  which  instruments, 
jars  containing  sterile  dressings,  bandages,  medicines  and  other  things 
needed  in  the  dressings  of  all  kinds  of  cases  can  be  placed. 

11.  One  instrument  cabinet. 

The  number  and  type  of  instruments  must  be  determined  by  each 
surgeon  according  to  the  local  needs. 

All  of  the  above  equipment  may  not  be  needed  in  many  plant 
dispensaries  while  others  may  need  a  more  elaborate  equipment. 
This,  however,  forms  an  average  for  most  surgical  offices. 

Sterilizing  Room. — As  an  adjunct  to  every  surgical  dispensary 
in  industry  there  should  be  a  well  equipped  sterilizing  room.  This 
should  consist  of  at  least  one  large  steam  sterilizer  for  the  steriHzation 
of  all  dressings  and  one  instrument  sterilizer.  The  rubber  gloves 
worn  by  the  surgeon,  the  basins  for  solutions,  the  dressings  and  in- 
struments and  in  fact  everything  coming  in  contact  either  directly 
or  indirectly  with  the  injured  parts  should  be  as  scrupulously  steril- 
ized as  when  used  in  an  operation.  In  a  well  organized  office  this 
can  be  done  without  any  undue  loss  of  time. 

Dressings,  Supplies  and  Bandages. — Surgical  gauze  should  be 
used  for  the  dressing  of  all  open  wounds.  Absorbent  cotton  which 
is  at  times  applied  by  some  is  not  suitable  because  of  the  difficulty  of 
removing  this  after  it  has  become  adherent  to  a  wound. 

I  have  found  the  following  procedure  the  most  economical  and 
most  efficient  in  preparing  dressings  for  at  least  a  hundred  cases  per 
day. 

1.  Surgical  gauze  is  bought  by  the  bolt. 

2.  Nurses  cut  this  into  different  size  dressings : 

(a)  Small,  three  layer  piece  of  gauze  for  finger  dressings  (1"  by 

2"). 
(6)  Slightly  larger,  three  layer  piece  of  gauze  (2"  by  4")  for 

31 


482  INDUSTRIAL   MEDICINE   AND    SURGERY 

hand  dressings,  or  for  small  wounds  about  the  head  or  other 
surface  of  the  body. 

(c)  Three  layer,  folded  piece  of  gauze  (4"  by  6")  for  the  larger 
wounds. 

(d)  Four  layer,  rolled  piece  of  gauze  (4"  by  10")  suitable  for 
encircling  the  arm  or  covering  considerable  surface  of  the 
body. 

(e)  Large  hemorrhage  pads  consisting  of  cotton  covered  with 
two  layers  of  gauze  folded  with  edges  turned  in  (6"  by  10") . 

(/)  Larger  hemorrhage  pads  (12"  by  18")  made  about  two 
inches  thick  for  use  in  severe  crushing  wounds  or  to  cover 
a  stump  where  the  Hmb  is  completely  severed. 

3.  Each  of  these  dressings  is  rolled  separately  in  a  piece  of  thin 
paper  carefully  twisted  at  either  end  so  that  the  dressing  is  completely 
and  thoroughly  covered. 

4.  These  are  then  placed  in  a  small  sack  the  size  of  a  ten  pound 
meal  bag  and  put  in  the  sterilizer  for  one  hour. 

5.  These  sterile  dressings  as  needed  are  put  in  large  covered  glass 
jars  kept  on  the  dressing  table.  In  using  them  the  nurse  or  doctor 
tears  off  the  tissue  paper,  unrolls  or  unfolds  the  dressing  without  touch- 
ing the  portion  which  goes  next  to  the  wound  and  lays  it  over  the  in- 
jured part.     All  dressings  in  the  first  aid  kit  are  similarly  prepared. 

Towels,  cotton  tampons,  sponges  and  similar  materials  are  also 
covered  with  paper  and  sterilized. 

Basins  are  put  in  cloth  bags  which  are  then  carefully  tied  with 
draw-strings  and  sterilized  in  the  same  manner. 

Rubber  gloves  are  rolled  in  pieces  of  cloth  and  sterilized. 

Bandages  are  among  the  most  expensive  items  in  the  dispensary 
if  bought  already  cut  in  1",  2",  3",  etc.,  sizes.  Very  good  gauze 
bandages  can  be  obtained  in  long,  solid  rolls,  wrapped  in  paper,  and 
cut  as  needed  with  a  knife  into  the  various  sizes.  Strong  cotton  band- 
ages are  also  necessary  especially  in  applying  splints.  Flannel 
bandages  are  used  frequently  about  swollen  joints  or  as  supports  in 
varicose  veins  of  the  leg.  All  of  these  materials  can  be  bought  in  bulk 
and  the  nurses  can  cut  and  roll  the  bandages  in  the  sizes  needed. 

Cotton  applicators  play  a  very  important  part  in  minor  surgery 
about  an  industry,  lodin  is  best  applied  to  surface  wounds  by 
means  of  these  applicators.  Also  applicators  and  a  bottle  of  iodin 
should  be  placed  in  every  room  about  the  plant  so  that  employees 
can  paint  iodin  on  their  wounds  at  once.  These  applicators  are  made 
by  rolling  a  small  piece  of  cotton  on  the  end  of  a  toothpick. 

Adhesive  plaster  is  used  extensively  in  dressing  injured  parts. 
This  should  be  bought  in  bulk,  rolls  14"  wide  and  approximately  three 
feet  long.     The  small  strip  used  so  commonly  to  hold  bandages  in 


THE    SURGICAL   DISPENSARY    STAFF 


483 


place,  or  often  to  replace  bandages,  can  be  cut  and  stuck  to  a  piece 
of  glass  the  size  of  a  window  pane,  thus  being  quickly  available  for  use. 

Employees  with  minor  injuries,  not  sufficiently  serious  to  prevent 
their  working,  can  have  their  efficiency  greatly  increased  or  diminished 
by  the  type  of  dressing  that  is  applied.  This  is  especially  true  in  in- 
juries about  the  hands.  Often  one  sees  a  small  cut  on  a  finger  band- 
aged until  the  whole  hand  and  wrist  are  encased.  The  psychological 
effect  of  such  a  dressing  on  an  employee  is  bad.  Therefore  the  smal- 
lest possible  dressing  should  be  applied  and  a  minimum  amount  of 
bandage  used  to  hold  it  securely  in  place.  As  few  joints  as  possible 
should  be  restricted  by  the  bandage. 

Wire  cages  or  protective  strips  of  tin  are  very  useful  in  protecting 
injured  fingers  and  adding  to  the  comfort  and  efficiency  of  the  em- 
ployee. These  are  placed  next  to  the  sterile  dressing  and  held  in 
place  by  a  bandage  or  adhesive  plaster.     (See  Fig.  71.) 


Fig.  71. — Tin  strips  which  act  as  a  protection  to  the  injured  finger  allowing  the  em- 
ployee to  continue  at  work. 

Splints  of  all  sizes  should  be  prepared  and  always  ready  for  im- 
mediate application  to  all  fracture  cases.  The  delay  in  preparing  a 
sphnt  for  the  immobilization  of  a  fracture  is  annoying  to  the  patient 
and  often  shows  a  lack  of  efficient  management  in  the  office. 

Before  leaving  this  question  of  dressings  the  author  desires  to 
re-enforce  what  has  been  said  regarding  the  use  of  sterile  dressings. 
About  two  years  ago  he  visited  five  surgical  dispensaries  in  plants  and 
five  private  offices  where  the  doctors  attended  many  minor  injury 
cases  for  insurance  companies.  In  only  three  of  the  plants  dispen- 
saries and  only  one  of  the  private  offices  were  sterile  dressings  used. 
In  the  others  gauze  was  bought  from  drug  stores  in  the  commercial, 


484  INDUSTKIAL    MEDICINE    AND    SURGERY 

so-called  sterile,  five  yard  rolls.  The  doctors  would  cut  off  the  neces- 
sary amount  of  gauze  needed  for  the  dressing  by  pulling  it  out  on  a 
table  and  cutting  it  with  unsterile  scissors.  Perhaps  the  first  piece 
used  was  sterile  but  certainly  none  of  the  remainder  could  be.  In- 
fections are  bound  to  be  more  prevalent  if  these  methods  are  used. 
One  doctor  never  used  gauze  but  simply  covered  the  -wound  with  the 
ordinary  commercial  bandage.  Every  surgeon  should  strive  to  make 
the  minor  surgery  carried  on  in  industry  as  ideal,  from  an  aseptic 
standpoint,  as  the  surgery  done  in  our  best  hospitals.  Such  methods 
have  wonderful  educational  value  in  teaching  the  employees  pre- 
vention. 

Sources  of  Accident  Cases. — The  great  bulk  of  accident  surgery 
naturally  is  derived  from  injuries  received  directly  as  the  result  of 
occupations  or  of  conditions  in  the  plant.  However,  many  employees 
receive  injuries  outside  the  plant  or  while  at  home.  These  outside 
accidents  have  come  to  be  known  as  "home  accidents"  in  contradis- 
tinction to  those  received  while  at  work. 

Major  home  accidents  like  serious  illnesses  are  usually  treated  by 
the  family  physician  or  the  surgeon  he  calls  in.  Often  when  the  visit- 
ing nurse  reports  neglectful  treatment  of  such  cases  the  plant  surgeon 
is  forced  to  take  charge. 

But  minor  home  accidents  are  frequently  neglected  by  the 
employees.  They  lie  around  the  house  for  days  with  a  swollen  ankle, 
the  result  of  a  sprain,  or  with  an  infected  hand  due  to  some  slight 
abrasion,  trying  home  remedies  and  otherwise  temporizing  with  the 
condition  rather  than  consult  a  physician.  Time  lost  from  these 
slight  injuries  is  excessive.  But  if  the  employee  knows  that  he  can 
report  to  the  plant  dispensary  and  receive  free  treatment  he  usually 
comes  to  work  in  order  to  see  the  doctor.  Proper  treatment  can  be 
instituted  and  the  case  supervised,  and  many  times  the  employee 
can  be  assigned  to  work  which  will  not  interfere  in  his  recovery. 

For  three  years  it  was  the  policy  of  the  plant  with  which  the  author 
was  connected  to  refer  all  home  accident  cases,  even  the  slight  in- 
juries, to  the  family  physicians.  We  limited  our  care  of  these  cases 
to  emergency  treatment  only.  Many  who  were  thus  referred  failed 
to  see  a  doctor  but  simply  remained  away  from  work  until  the  injured 
part  healed.     Undue  loss  of  time  from  work  resulted. 

Gradually  we  began  to  treat  these  home  accidents  when  they  called 
at  the  office.  More  and  more  of  the  employees  took  advantage  of 
this  until  in  1916  there  were  4570  home  accidents  cared  for  by  the 
plant  surgeons.  Approximately  95  per  cent,  of  this  number  lost  no  time 
from  work,  except  that  due  to  reporting  to  the  office  for  their  daily 
dressing.  With  the  old  policy  at  least  50  per  cent,  of  these  cases 
would  have  remained  at  home,  many  because  it  was  necessary  to  go 


THE    SU'RGICAL    DISPENSARY    STAFF  485 

to  their  family  physician  for  dressings  and  naturally  they  would  not 
report  for  work  for  a  part  of  the  day. 

Proof  of  the  value  of  this  system  is  seen  in  the  following  extract  from 
the  safety  engineer's  report  to  the  general  superintendent: 

''The  number  of  home  accidents  treated  by  the  hospital  has  risen 
from  2896  in  1915  to  4570  in  1916,  an  absolute  increase  of  57.8  per 
cent.,  or  a  relative  increase  of  32  per  cent.  The  reason  that  the  em- 
ployees are  making  more  use  of  the  hospital  in  cases  of  accidents 
occurring  outside  the  plant  is  due  to  the  more  liberal  policy  of  the 
hospital  in  treating  home  cases,  which  was  adopted  with  a  view  of 
reducing  time  loss  in  these  cases.  That  this  new  policy  has  produced 
most  satisfactory  results  there  is  no  doubt." 

Occasionally  one  of  these  injured  cases,  for  which  the  concern  is  in 
no  way  responsible,  will  develop  complications  which  adds  greatly 
to  the  expense  of  continuing  this  free  treatment.  However,  if  the 
surgeon  has  started  free  care,  when  the  case  seemed  only  a  minor 
affair,  he  must  continue  the  same  policy  when  it  becomes  serious. 

The  expense  connected  with  the  treatment  of  these  minor  home 
accidents,  even  with  the  occasional  serious  case  arising,  is  more  than 
compensated  by  the  increased  efficiency  of  these  employees  and  the 
diminution  in  time  loss. 

Schedule  for  Dressings. — Much  loss  of  time  from  work  can  result 
from  lack  of  system  in  the  reporting  of  employees  to  the  hospital 
for  their  dressings.  If  employees  are  simply  told  to  "come  back  to- 
morrow for  a  dressing"  most  of  them  will  report  the  first  hour  of 
work  with  the  result  that  the  congestion  in  the  office  interferes  greatly 
in  the  surgeon's  work  and  unnecessary  delay  in  treatment.  To 
avoid  this  a  small  hospital  card,  or  pass,  can  be  given  to  each  in- 
jured case  on  which  the  date  and  hour  for  the  next  dressing  is  marked 
by  the  nurse  at  each  visit.  By  our  system  ten  patients .  reported 
every  twenty  minutes. 

PREVENTIVE  SURGERY 

Preventive  surgery  is  a  direct  outgrowth  of  human  maintenance 
in  industry.  It  is  still  a  new  science  in  the  medical  field  but  the  time 
is  coming  when  it  will  receive  the  same  recognition  as  is  now  allotted 
to  preventive  medicine.  In  practical  operation  in  industry  it  in- 
cludes the  following: 

1.  The  prevention  of  accidents. 

2.  The  prevention  of  complications  when  accidents  occur. 

3.  The  prevention  of  undue  loss  of  time. 

4.  The  prevention  of  permanent  loss  of  function. 

5.  The  prevention  of  threatened  illnesses,  premature  breakdowns, 
lowered  efficiency,  etc.,  by  adopting  certain  surgical  procedures. 


486  INDUSTRIAL    MEDICINE    AND    SURGERY 

The  prevention  of  accidents  has  been  thoroughly  dealt  with  in 
Chapters  XXI  and  XXII.  The  following  letter  written  by  the  author, 
early  in  his  career  as  a  plant  surgeon,  to  the  general  superintendent 
of  an  industry  will  illustrate  some  of  the  preventive  methods  success- 
fully adopted  since  then  by  this  and  many  other  concerns.  Surgeons 
entering  this  new  field  of  medicine  will  find  that  the  recommendations  ^ 
submitted  in  a  memorandum  such  as  this  do  not  always  receive  the 
prompt  approval  of  the  management,  but  patience  and  perseverance 
will  usually  result  in  the  final  adoption  of  these  methods. 

*'Mr. :  Safety  first  appliances  installed  last  year  prevented 

a  great  number  of  accidents.  An  excellent  example  is  afforded  by  the 
reduction  of  accidents  due  to  conveyors.  In  1912  there  were  101 
accidents  directly  due  to  the  new  conveyors,  while  last  year  only 
four  accidents  could  be  traced  to  this  cause. 

"A  careful  study  of  all  the  machines  and  processes  in  the  plant 
would  reveal  many  other  places  where  safety  appliances  would  reduce 
the  accident  rate.  While  the  medical  staff  and  the  safety  engi- 
neer are  constantly  striving  to  anticipate  accidents  by  installing  these 
appliances,  yet  the  man  on  the  job  is  in  the  best  position  to  perceive 
hazardous  conditions,  especially  if  he  is  trained  until  he  is  imbued 
with  the  spirit  of  prevention. 

"I  wish  to  recommend  that  the  doctors,  the  safety  engineer,  the 
management  and  all  the  employees  be  urged  this  year  to  put  forth  a 
great  effort  to  prevent  both  major  and  minor  accidents  and  compli- 
cations, especially  infections. 

"The  first  step  in  this  direction  is  to  appoint  an  accident  'prevention 
man  in  every  department  or  two  or  three  such  men  in  the  larger 
departments.     Their  duties  would  be: 

"l.  To  report  the  need  of  any  new  safety  appliances  to  the  Safety 
Engineer.  Quite  often  the  necessity  for  some  safety  appliance  is  not 
recognized  until  after  a  serious  accident  has  occurred.  This  prevention 
man  would  constantly  study  conditions  in  order  to  foresee  such  a  need. 

"2.  To  study  the  causes  of  minor  accidents  and  endeavor  at  all 
times  to  remove  these.  For  example  this  man  would  soon  develop 
the  habit,  and  spread  it  to  others,  of  picking  up  every  loose  nail  from 
the  fioor  or  of  removing  obstructions  which  might  cause  falls. 

"3.  To  see  that  every  employee  who  receives  an  injury,  no  matter 
how  slight,  paints  it  at  once  with  iodin  and  then  reports  to  the  doctor. 

"4.  To  prevent  employees  from  rendering  first  aid  to  one  another, 
as  for  example  the  removing  of  foreign  particles  from  the  eye  or  extract- 
ing slivers. 

"5.  To  receive  reports  from  the  doctor  concerning  injured  employees 
who  fail  to  report  at  once,  or  concerning  accidents  in  his  department 
which  apparently  could  have  been  prevented. 


THE    SURGICAL   DISPENSARY    STAFF  487 

"6.  To  receive  periodical  instructions  from  the  safety  engineer  and 
from  the  doctors  on  all  matters  of  prevention  and  on  certain  first  aid 
methods  which  will  make  them  competent  to  render  the  same  if 
occasion  arises. 

"The  number  of  safety  appliances  which  have  been  installed  follow- 
ing suggestions  from  the  employees  demonstrate  how  valuable  these 
men  can  be  in  this  respect. 

"Last  year  610  cases  of  infection  developed  after  injuries.  Twelve, 
or  1.9  per  cent.,  of  these  used  iodin  and  reported  to  the  doctor  at 
once.  Twenty-four,  or  3.9  per  cent.,  reported  at  once  without  using 
iodin. 

"These  thirty-six  cases  were  only  slightly  infected  and  none  of 
them  required  opening  nor  lost  time  from  work.  The  remaining 
574  cases  reported  from  one  day  to  two  weeks  after  receiving  their 
injuries;  520  of  these  required  opening  and  all  of  them  lost  time 
from  work,  with  an  additional  decrease  in  their  efficiency  while  working 
with  a  finger  or  hand  bandaged.  Of  this  number  42  per  cent, 
used  iodin  sometime  later,  while  52  per  cent,  failed  to  use  it  at 
all.  From  our  past  experience  we  know  that  the  immediate  use  of 
iodin  and  then  reporting  to  the  doctor  at  once  would  have  reduced 
this  number  of  infections  at  least  90  per  cent.  An  alert  prevention 
man  in  the  department  would  be  one  of  the  best  means  of  training 
all  employees  to  observe  these  rules. 

"It  is  a  common  practice  for  some  man  to  try  to  remove  a  sliver 
from  a  fellow  employee's  hand.  Often  the  part  is  so  lacerated  that 
an  entrance  for  infection  is  the  result;  or  only  a  part  of  the  sliver  is 
removed,  the  remainder  being  discovered  a  few  days  later  when  the 
member  becomes  infected.  Great  damage  is  often  done  to  the  eye 
by  similar  attempts  to  render  first  aid  by  an  employee.  Our  preven- 
tion man  could  forestall  these  misdirected  efforts. 

"Our  figures  are  very  striking  in  regard  to  wounds  from  splinters. 
Two  hundred  and  eighty  employees  reported  to  the  doctor  on  account 
of  sliver  wounds  last  year.  One  hundred  and  twelve,  or  40  per  cent., 
of  these  reported  late  with  the  part  infected.  All  had  either  success- 
fully or  otherwise  endeavored  to  remove  the  splinter  themselves  or 
the  same  effort  had  been  made  by  a  fellow  employee  or  some  member 
of  the  patient's  family.  None  of  the  cases  reporting  early  to  the 
doctor,  who  removed  the  splinter  under  aseptic  precautions,  become 
infected. 

"Occasionally  a  very  serious  accident  occurs  where  first  aid  must 
be  rendered  at  once  in  the  department.  In  those  departments  where 
these  major  accidents  are  liable  to  occur  we  have  placed  first  aid  kits 
and  two  men  have  been  carefully  instructed  by  the  doctor  in  the  various 
first  aid  methods.     This  system  should  be  extended  so    that    the 


488  INDUSTRIAL    MEDICINE    AND    SURGERY 

prevention  man  in  every  department  is  a  thoroughly  trained  first 
aid  expert.  These  serious  accidents  may  occur  in  the  most  unex- 
pected places. 

"Each  prevention  man  should  have  at  least  two  understudies  who 
can  in  turn  take  charge  of  this  prevention  work  if  occasion  arises. 
Such  a  system  would  give  us  missionaries  who  would  spread  the  spirit 
of  prevention  throughout  the  working  force, 

"I  would  further  recommend  that  each  department  be  given  arating 
according  to  their  percentage  of  accidents  per  employee  last  year 
and. that  a  contest  be  developed  to  see  which  department  will  have 
the  greatest  percentage  of  reduction  in  accidents  each  year.  To 
further  stimulate  this  effort  a  bonus  should  be  given  to  the  first, 
second  and  third  most  successful  departments  in  carrying  out  this 
program  of  prevention." 

The  above  letter  surely  demonstrates  that  this  branch  of  prevent- 
ive surgery  is  only  limited  by  the  vision  of  the  responsible  workers 
in  this  field.* 

The  prevention  of  undue  loss  of  time  from  work  is  best  attained 
by  treating  every  case  of  injury  as  serious  from  its  inception 
until  completely  cured.  Temporizing  with  slight  infections,  or 
with  sprained  backs;  neglecting  to  diagnose  early  every  case  of  frac- 
ture, or  by  considering  some  cases  of  apparent  sprains  as  trivial,  and 
later  discovering  that  a  true  fracture  is  delaying  the  recovery;  or 
sending  some  injured  cases  home  when  they  really  should  have  the 
advantages  of  the  best  hospital  treatment,  are  all  examples  of-  undue 
loss  of  time  from  work  by  injured  employees  which  it  is  within 
the  power  of  the  surgeon  to  prevent. 

Early  diagnosis,  the  adoption  from  the  very  first  of  the  best 
line  of  treatment,  constant  watchfulness  for  compHcations,  and 
starting  early  to  restore  function  in  an  injured  part  are  the  best  means 
of  preventing  permanent  deformities.  In  order  to  accompHsh  this 
the  surgeon  must  be  constantly  on  the  job.  He  cannot  leave  impor- 
tant dressings,  or  the  decision  as  to  when  massage  or  passive  motion 
shall  begin  in  an  injured  member,  nor  any  other  important  point  of 
judgment  to  some  inexperienced  interne.  He  must  feel  the  full 
responsibihty  of  the  case  and  act  quickly  and  wisely  if  he  is  to  be  a 
true  preventive  surgeon. 

The  constant  supervision  of  the  physical  status  of  a  large  group  of 
people,  such  as  is  carried  on  in  certain  industries,  reveals  many  con- 
ditions which  need  surgical  interference.  Some  of  these  offer  oppor- 
tunity for  classical  operations  but  are  not  really  essential  to  the  health 
or  efficiency  of  the  employees.  Others,  which  apparently  cause  no 
inconvenience  to  the  employee  at  the  time,  urgently  need  surgical 
care  in  order  to  prevent  future  illnesses  or  premature  break-downs. 


THE    SURGICAL    DISPENSARY    STAFF  489 

Frequently  these  conditions  are  causing  an  unknown  loss  of  efficiency 
to  the  workmen  which  could  be  relieved  by  surgical  interference. 

This  type  of  surgery  requires  the  most  careful  judgment  on  the 
part  of  the  surgeon.  It  is  not  so  difficult  to  convince  a  patient  suffer- 
ing from  some  acute  surgical  condition  causing  intense  pain  to  undergo 
an  operation,  but  excellent  arguments  must  be  presented  in  order  to 
persuade  an  employee  in  apparently  good  health  to  submit  to  one  of 
these  preventive  surgical  operations.  The  economic  result  is  the  best 
argument  which  can  be  advanced.  If  an  employee  can  be  shown 
that  the  removal  of  some  condition,  to  which  he  has  paid  little  attention 
in  the  past,  will  tend  to  improve  his  health,  will  prolong  the  period  of 
his  working  capacity  and  will  give  him  an  immediate  increased  effi- 
ciency he  will  usually  welcome  such  surgical  procedure.  The  surgeon 
must  be  sure  of  his  results  before  recommending  operations  on  these 
grounds. 

One  of  the  most  classical  examples  of  this  type  of  preventive  surgery 
is  afforded  by  the  work  of  our  oral  surgeons.  A  few  years  ago  Billings 
and  others  called  our  attention  to  the  part  played  by  focal  infections 
in  rheumatism,  arthritis,  endocarditis  and  similar  conditions.  In  order 
to  relieve  people  suffering  with  these  diseases,  search  for  foci  of  infec- 
tions was  made  and  the  same  were  removed.  The  eradication  of  focal 
infections  to  prevent  the  occurrence  of  these  diseases  followed  in  logical 
sequence. 

The  majority  of  up-to-date  industrial  surgical  dispensaries  now 
have  their  dental  departments  where  this  type  of  preventive  surgery 
can  be  practised.     (See  Chapter  V.) 

Diseased  tonsils  is  one  of  the  most  common  conditions  found  among 
employees.  The  condition  is  equally  prevalent  among  males  and 
females.  They  seem  to  cause  more  time  loss  and  complications  among 
the  girl  employees,  however,  than  among  the  men.  Recurring  attacks 
of  tonsillitis  seem  to  occur  with  equal  frequency  among  both  sexes  but 
headaches,  nausea  and  backaches,  all  of  which  have  been  relieved  by 
the  removal  of  the  diseased  tonsils,  caused  the  greater  loss  of  time 
Among  the  girls. 

In  1914  the  author  began  to  recommend  the  removal  of  tonsils  to 
all  employees  who  showed  signs  of  definite  diseased  conditions,  with 
resulting  loss  of  efficiency,  due  to  the  tonsils.  As  an  inducement  to 
the  employees  to  have  this  operation  performed,  the  surgeon  offered 
his  services  free  of  charge.  For  those  who  could  not  afford  to  pay  for 
a  bed  at  the  hospital  arrangements  were  made  for  free  hospital  care; 
the  others  were  charged  only  a  nominal  hospital  fee.  Approximately 
250  tonsillectomies  were  performed  for  the  employees  by  the  sm-geon 
and  a  far  greater  number  had  the  operation  performed,  by  the  surgeon 
of  their  choice,  on  the  recommendation  of  the  medical  staff.     These 


490  INDUSTRIAL    MEDICINE    AND    SURGERY 

operations,  which  the  author  performed,  were  always  done  in  the 
hospital  under  the  most  aseptic  precautions  and  the  patients  were 
required  to  remain  there  at  least  24  hours.  All  cases  recovered 
without  any  comphcations  except  two  who  had  severe  hemorrhages. 
In  every  case  it  was  carefully  explained  to  the  employee  that  the 
operation  was  offered  on  the  sole  responsibihty  of  the  surgeon  and  not 
as  an  activity  of  the  concern. 

In  practically  every  instance  this  preventive  surgery  has  given  the 
most  excellent  economic  results.  Male  employees  who  frequented  the 
doctor's  office,  complaining  of  sprained  backs,  lumbago  and  backache 
were  reheved  of  these  troubles  in  many  instances.  The  girl  em- 
ployees who  reported  to  the  office  on  account  of  headaches,  attacks  of 
nausea  and  fainting,  signs  of  fatigue,  frequent  colds  and  other  con- 
ditions traceable  to  this  focal  infection,  seldom  called  at  the  office  on 
account  of  these  conditions  after  the  tonsillectomy.  Many  of  these 
employees  were  absent  four  or  five  times  during  the  course  of  a  year 
on  account  of  acute  tonsilHtis.  The  lost  time  averaged  from  two  days 
to  a  week  in  each  attack.  Where  the  tonsils  were  completely 
enucleated  all  of  these  employees  ceased  to  lose  time  on  account  of 
this  disease.  In  only  two  of  the  author's  series,  due  to  small  tags  of 
tonsils,  did  subsequent  attacks  occur. 

In  1915  the  records  of  28  employees,  on  whom  the  author  had 
operated  for  diseased  tonsils,  were  carefully  scrutinized  to  ascertain 
whether  or  not  the  desired  economic  results  were  actually  being 
obtained.  This  scrutiny  showed  that  for  the  two  years  previous  to  the 
tonsillectomies  these  employees  had  made  160  visits  to  the  doctor's 
office,  chiefly  on  account  of  tonsillitis,  colds,  sore  throat,  headache, 
conjunctivitis,  nausea,  pains  in  back,  pains  in  joints,  swollen  glands 
and  general  fatigue.  During  the  same  period  this  group  of  employees 
had  remained  at  home  71  times  on  account  of  sickness.  Their  chief 
illnesses  were  tonsillitis,  colds,  headache,  rheumatism,  neuralgia,  influ- 
enza, and  a  few  other  conditions  which  seemed  to  have  no  connection 
with  the  tonsils. 

For  the  two  year  period  following  their  tonsillectomies  this  group 
made  68  visits  to  the  doctor's  office  and  were  absent  from  work  only  33 
times.  A  reduction  in  both  instances  of  over  50  per  cent,  in  time 
loss.     The  conditions  causing  these  absences  were  as  follows: 

4  on  account  of  colds 

4  on  account  of  stomach  trouble 

4  on  account  of  rheumatism 

5  on  account  of  influenza 

6  on  account  of  dysmenorrhea 
2  on  account  of  bronchitis 

2  on  account  of  sore  throat  and  earache 


THE    SURGICAL   DISPENSARY   STAFF  491 

3  on  account  of  headaches 
1  on  account  of  pleurisy 
1  on  account  of  appendicitis 
1  on  account  of  cholecystitis 

The  war  interfered  with  the  obtaining  of  complete  statistics  on 
all  of  the  tonsillectomies  but  I  am  positive  that  the  removal  of  dis- 
eased tonsils  among  employees,  as  well  as  among  any  other  group 
of  people,  will  result  in  greatly  improved  health  and  is  a  measure  of 
the  greatest  economic  importance  to  industry. 

It  is  amazing  with  what  ease  a  small  epidemic  of  tonsillitis  will 
spread  among  a  group  of  employees  working  in  the  same  department. 
To  avoid  these  epidemics,  if  the  employees  will  not  submit  to  the  opera- 
tion, I  have  made  it  a  point  to  recommend  their  transfer  to  work  which 
segregates  them  as  far  as  possible  from  their  fellow  workmen. 
Under  the  chapter  on  "Hand  Infections"  the  relationship  between 
these  and  diseased  tonsils  is  pointed  out  and  affords  another  example 
of  the  importance  of  this  type  of  preventive  surgery. 

The  presence  of  an  unsightly  birth  mark  or  nevus  on  an  employee's 
face,  or  of  a  hairy  mole  on  the  lip,  or  of  a  large  sebaceous  cyst  on  the 
scalp  is  often  the  cause  of  lowered  efficiency  in  an  employee.  The 
condition  may  make  one  self-conscious  or  backward,  or  it  may  re- 
sult in  a  foreman  forming  a  wrong  judgment  concerning  the  ability 
of  the  workman.  The  surgeon  can  gain  the  confidence  of  these 
employees  and  explain  the  resulting  damage  which  these  condi- 
tions are  causing  them.  After  their  confidence  is  gained  most  em- 
ployees will  welcome  the  opportunity  of  having  these  unsightly  growths 
removed.  The  gratitude  of  these  patients  and  the  energy  they  dis- 
play in  overcoming  the  prejudice  which  existed  either  in  their  own 
minds,  or  in  the  minds  of  others,  well  repays  the  surgeon  for  his  in- 
terest in  them.  Surgery  performed  for  the  purpose  of  preventing 
decreased  efficiency  is  perhaps  a  new  viewpoint  but  it  is  a  field  which 
every  surgeon  in  industry  has  an  opportunity  to  thoroughly  investigate. 

The  above  examples  of  the  scope  of  preventive  surgery  are  suffi- 
cient to  demonstrate  that  this  field  is  comparable  in  importance  and 
interest  to  the  older  and  well-recognized  work  of  preventive  medicine. 


CHAPTER  XXXII 

FIRST  AID 

First  aid,  as  used  in  industrial  surgery,  consists  of  such  surgical 
or  medical  procedures  as  may  be  given  to  a  patient  by  a  layman  pend- 
ing the  arrival  of  a  physician  or  during  the  transportation  of  the  patient 
to  the  physician.  Untrained  individuals  often  render  first  aid  care 
on  their  own  responsibility.  Such  assistance  is  often  necessary,  but 
to  be  of  the  greatest  value  it  should  be  administered  by  a  thoroughly 
trained  first  aid  expert. 

During  the  last  ten  years  many  advocates  of  first  aid  care  sprang 
up  throughout  industry.  Lay  associations  were  formed  and  doctors, 
without  sufficient  training  or  experience  in  industrial  surgery,  were 
called  in  to  lecture  on  first  aid.  First  aid  diplomas  have  even  been  issued, 
giving  the  layman  a  sense  of  great  confidence  in  his  ability  to  care  for  the 
injured.  Many  have  advocated  a  national  first  aid  movement  which 
would  train  millions  of  our  civilian  population  as  to  just  what  to  do 
immediately  for  the  injured  man  or  woman.  If  the  teachings  of  such 
an  association  were  Hmited  to  three  or  four  simple  but  essential  p'rin- 
ciples,  and  the  rest  of  their  energy  was  devoted  to  "What  Not  to  Do," 
there  is  no  doubt  but  that  such  a  movement  would  result  in  the  saving 
of  thousands  of  lives  during  the  course  of  a  year.  But  if  the  efforts 
of  these  half-trained  first  aiders  were  allowed  to  go  unbridled  among 
minor  injury  cases  many  of  them  would  not  see  a  doctor  until  some 
serious  complication  had  developed. 

Recognizing  the  importance  of  standard  first  aid  care  to  the  injured 
civihan  forces,  many  different  individuals  and  associations  have  en- 
deavored to  work  out  a  logical  system  of  standardization.  Dr.  Joseph 
Colt  Bloodgood's  questionnaires  and  investigations  on  this  subject 
have  resulted  in  stimulating  these  efforts,  even  though,  as  Bloodgood 
himself  says,  this  work  resulted  only  in  the  expenditure  of  considerable 
sums  of  money  and  the  accumulation  of  so  much  material  that  he  alone 
could  not  arrive  at  any  logical  conclusions. 

The  committee  on  Standardization,  under  the  leadership  of  Dr. 
Rucker,  of  the  United  States  Public  Health  Service,  took  over  the 
data  which  Dr.  Bloodgood  had  collected  and  started  a  further  investiga- 
tion on  this  subject.  The  war  interfered  with  this  study,  but  it  is  hoped 
that  when  conditions  once  more  become  normal  much  valuable  informa- 
tion will  be  presented  to  the  country  as  a  result  of  the  work  of  this  Com- 

492 


FIRST    AID 


493 


mittee.  The  Conference  Board  of  Industrial  Physicians,  The  National 
Electric  Light  Association,  The  Bureau  of  Mines — Department  of  the 
Interior,  The  National  Safety  Council  and  other  organizations  have 
brought  out  valuable  contributions  on  the  subject  of  first  aid. 

While  excellent  results  have  been  obtained  by  many  of  these 
standardized  first  aid  methods  when  properly  supervised  by  physicians, 
yet  one  outstanding  criticism  is  applicable  to  the  majority,  viz.,  they 
are  too  extensive  and  tend  to  make  embryo  physicians  out  of  the 
trained  first  aid  assistant. 

r  ■"'^1 


Fig.  72.- 


-First  aid  station  at  Colorado  Fuel  &  Iron  Co. 
attendance. 


A  trained  nurse  is  always  in 


In  organized  industrial  surgery  three  first  aid  systems  have  been 
developed  which  deserve  mention: 

1.  The  best  system  is  found  in  a  few  industries  which  employ  a 
sufficient  number  of  doctors  and  nurses  on  the  premises  at  all  times 
so  that  immediate  emergency  treatment  by  a  qualified  physician  can 
be  given  to  all  injured  employees.  The  only  first  aid  care  needed 
in  such  industries  is:  the  application  of  some  antiseptic  at  once 
by  the  employee  himself  or  by  some  fellow  employee  to  open  wounds; 
the  resuscitation  of  employees  who  have  been  overcome  by  gas,  elec- 
tric shock  or  similar  conditions;  the  control  of  hemorrhage  by  the  ap- 
pHcation  of  hemorrhage  pads  or  the  tourniquet;  and  the  removal  of 
the  injured  party  from  a  position  to  preclude  further  injury.  Thus 
in  those  industries  where  a  doctor  can  be  summoned  to  a  department 
within  four  or  five  minutes  certain  employees  should  be  taught  these 
simple  first  aid  methods.     Above  all  every  employee  should  be  warned 


494 


INDUSTRIAL    MEDICINE    AND    SURGERY 


against  unduly  moving  of  the  injured,  against  manipulation  of  broken 
parts,  against  ever  touching  the  open  wounds  and  certainly  against 
endeavoring  to  remove  foreign  bodies.  If  the  surgeon,  on  his  arrival, 
needs  assistance  in  these  maneuvers  he  will  request  it  from  some  in- 
telligent employee  in  the  department.  The  majority  of  persons 
injured  in  the  plant  can  be  brought  to  the  doctor's  office  at  once  where 
proper  emergency  care  can  be  given.  For  these  the  only' first  aid 
needed  is  the  application  of  some  antiseptic  to  the  open  wound;  this 
can  usually  be  done  by  the  employee  himself  or  by  some  fellow  em- 
ployee. In  these  plants  the  nurses  often  respond  to  calls  from  de- 
partments and  they  become  quite  expert  in  rendering  the  necessary 
first  aid.  They  take  charge  of  transporting  the  patient  to  the  doctor's 
office  or  summoning  the  physician  if  they  think  it  unwise  to  move 
him  at  once. 


Fig.  73. — A  first  aid  station  in  the  Ford  automobile  factory. 


2.  The  second  method  in  vogue  in  some  industries  consists  of  first 
aid  stations  in  various  parts  of  the  plant,  with  a  well  trained  first  aid 
man  or  a  qualified  nurse  in  charge.  Injured  employees  are  taken  at 
once  to  these  first  aid  stations,  or  the  attendants  are  called  to  them 
when  the  injured  party  cannot  be  moved.  These  assistants  render 
the  necessary  first  aid  care  and  then  transport  the  injured  to  the 
doctor  or  immediately  summon  the  physician  to  the  case.  In  one 
industry  medical  students  are  employed  for  three  hours  a  day  on  this 
work,  so  rotating  that  it  does  not  materially  interfere  with  their  studies. 


FIRST    AID  495 

Here  again  the  first  aid  is  limited  to  the  apphcation  of  antiseptics 
and  a  sterile  dressing,  checking  of  hemorrhage,  combating  shock  and 
resuscitation.  All  manipulations  or  direct  treatment  of  the  wound 
is  left  to  the  physician  who  is  close  at  hand.     (Fig.  73.) 

3.  The  third  method  is  employed  in  industries  engaged  in  unusually 
hazardous  occupations  and  where  the  employees  are  scattered  over 
a  large  territory,  as,  for  example,  in  mines,  in  large  steel  plants,  ship- 
building yards,  etc.  While  physicians  are  employed  by  these  con- 
cerns, yet  they  are  usually  stationed  at  the  plant  hospital  which  may 
be  a  haK  mile  or  a  mile  away  from  the  point  where  some  of  the  work- 
men are  employed.  The  best  organized  medical  work  in  such  con- 
cerns has  recognized  the  need  of  competent  first  aid  assistants  scattered 
throughout  the  working  forces.  To  meet  the  situation  the  physician 
has  trained  first  aid  teams  in  every  department.  The  teams  are  taught 
how  to  immediately  apply  an  antiseptic  to  open  wounds  and  then 
cover  them  with  a  sterile  dressing;  how  to  check  hemorrhages  and 
combat  shock;  how  to  give  artificial  respiration;  how  to  apply  splints 
to  fractured  limbs  and  the  best  means  of  transporting  the  injured 
employee  to  the  doctor.  In  some  instances  the  medical  staff  depends 
altogether  on  these  teams  to  render  first  aid  care  and  to  bring  the  pa- 
tient to  the  hospital,  while  in  others  the  doctor  is  summoned  from  the 
hospital  by  one  member  of  the  team  while  the  others  are  rendering  the 
necessary  care.  The  latter  plan  is  better,  as  the  physician  can  thus 
take  charge  of  the  case  earlier  than  if  he  waits  for  the  seriously  injured 
to  be  conducted  to  him. 

During  the  early  popularity  of  the  first  aid  movement  many  more 
elaborate  schemes  than  the  above  were  promulgated.  In  1914  the 
author  visited  a  number  of  industries  in  order  to  study  this  question 
of  first  aid.  He  was  astounded  at  the  extensive  preparation  for  this 
work  which  some  concerns  had  made.  For  example,  one  industry  had 
provided  a  very  pretentious  first  aid  kit,  which  contained  a  complete 
set  of  instruments,  all  varieties  of  commercial  splints,  six  different 
sized  bandages  but  no  sterile  dressings;  one  compartment  of  this  kit 
was  set  aside  for  medicines  and  in  this  was  found  such  drugs  as  castor 
oil,  Epsom  salts,  whiskey,  aromatic  spirits  of  ammonia,  morphin, 
cocain.  Sun  cholera  tablets,  a  cough  mixture,  Jamaica  ginger  and  several 
others  which  would  enable  the  layman  to  treat  medical  cases  as  well 
as  to  render  a  questionable  first  aid  to  the  injured.  One  can  see  at  a 
glance  that  such  power  as  this  placed  in  the  hands  of  a  layman  was 
dangerous  and  would  tend  to  eliminate  the  physician  from  a  field 
where  he  was  most  urgently  needed.  The  very  best  types  of  first 
aid  work  were  found  in  those  industries  where  the  doctor  insisted 
on  seeing  the  injured  employee  just  as  soon  after  the  accident  oc- 
curred as  it  was  possible  to  bring  the  patient  to  the  surgeon  or  the 


496  INDUSTRIAL    MEDICINE    AND    SURGERY 

surgeon  to  the  patient.  In  those  plants  where  the  hazards  of  the 
occupations  necessitated  first  aid  kits  the  contents  were  Hmited  to  the 
necessary  bandages  and  sterile  dressings,  a  few  splints,  an  antiseptic, 
a  tourniquet  and  aromatic  spirits  of  ammonia  to  be  used  when  a 
stimulant  was  necessary.  Short,  terse  instructions  went  with  each 
kit  and  limited  the  layman  in  what  he  could  do  for  the  patient  and 
impressed  upon  him  the  importance  of  getting  the  physician  on  the 
job  at  once.  The  first  aid  methods  consisted  only  of  preventing  in- 
fection, checking  hemorrhages,  combating  shock  and  resuscitation. 
All  other  treatment  was  left  to  the  surgeon. 


Fig.  74. — The  contents  of  the  best  first  aid  kits  are  limited  to:  a,  Tincture  of 
iodin  and  applicators;  b,  bandages  and  sterile  dressings;  c,  some  form  of  tourniquet; 
d,  a  few  splints;  e,  aromatic  spirits  of  ammonia. 

As  a  result  of  this  study  the  author  has  adopted  the  following  first 
aid  rules: 

1.  All  injured  employees,  no  matter  how  slight  the  injury,  must 
report  to  the  doctor's  office  at  once. 

2.  If  the  employee  is  so  injured  that  he  cannot  walk  to  the  doctor's 
office  the  physician  must  be  summoned  to  him  at  once. 

3.  Every  open  wound  which  penetrates  the  skin,  no  matter  how 
slightly,  must  be  painted  with  iodin  at  once.  The  foreman  or  the 
selected  first  aid  man  in  the  department  must  pour  iodin  into  the 
extensive  open  wounds  at  once.  For  this  purpose  a  small  rack, 
containing  a  bottle  of  iodin  and  a  bottle  of  applicators  must  be  placed 
in  a  conspicuous  spot  in  every  department  (as  many  as  twelve  of  these 
racks  have  been  placed  in  the  larger  departments).  Instructions  on 
each  rack  and  on  the  bulletin  boards  warn  the  employees  to  use 
iodin  at  once  in  the  case  of  injury  and  then  immediately  to  report  to  the 
doctor.     (See  Fig.  75.) 

4.  First  aid  kits  must  be  placed  in  all  departments  where  machinery 


FIRST    AID 


497 


is  used  or  where  other  hazardous  processes  obtain.  A  wooden  box, 
15"  X  9}4"  X  7"  fastened  by  a  strong  clasp  and  equipped  with  one 
handle,  wh  ch  acilitates  carrying  is  to  be  used  as  a  conta  ner  for  the 
first  aid  material.  This  box  is  divided  into  four  compartments: 
a  large  one  for  the  various  sized  dressings,  a  smaller  one  for  bandages, 
the  tourniquet  and  a  spool  of  adhesive  plaster,  a  third  compartment 
just  large  enough  to  hold  the  container  for  the  iodin  and  applicators 

1 


Fig.  75. 


-Rack  used  by  author  to  hold  bottles  of  iodin  and  applicators, 
placed  in  conspicuous  places  throughout  the  working  place. 


These  are 


and  a  fourth  small  compartment  into  which  is  placed  the  aromatic 
spirits  of  ammonia.     (See  Figs.  76  and  77.) 

(a)  The  dressings  are  placed  in  three  cloth  bags,  according  to 

their  size,  as  follows: 

Small   sterile    dressings,   rolled   individually  in   tissue   paper 

for  finger  bandages  or  other  small  wounds. 

Middle  sized   sterile   dressings,   rolled  individually  in  tissue 

paper  for  the  larger  wounds. 

Four  large  sterile  hemorrhage  pads,  12"  X  18"  (see  Chapter 

32 


498 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Fig.  76. — Author's  first-aid  kit. 


Fig.  77. — First  aid  kit  with  four  compartments  packed. 


FIRST    AID  499 

XXX)  rolled  individually  in  tissue  paper,  to  be  used  as  com- 
presses in  case  of  hemorrhages  or  as  dressings  for  large  wounds. 

(6)  The  bandages  consist  of  l'\  2"  and  3"  gauze  bandages  (four 
of  each)  and  four  strong  cotton  bandages  3"  by  10  yds. 

(c)  A  spool  of  3"  adhesive  plaster  must  be  included  in  every  kit, 
to  be  used  to  hold  dressings  in  place  when  bandages  cannot 
be  applied. 

(c?)  The  tourniquet  consists  of  a  3"  X  5  yd.  rolled,  strong,  cotton 
bandage,  plainly  marked  ^''To  he  used  in  case  of  hemorrhage '' 
(the  author  discarded  the  use  of  the  rubber  tourniquet  in  the 
hands  of  lay  assistants  because  of  the  dangers  arising  from  its 
use.  The  first  aiders  were  instructed  to  place  a  compress  over 
the  artery  above  the  bleeding  point  and  to  bandage  the  same 
as  tightly  as  possible  with  this  cotton  bandage). 

(e)  lodin  is  supplied  for  the  purpose  of  immediate  application  to 
all  open  wounds,  no  matter  how  extensive.  This  is  either  to  be 
painted  on  with  an  applicator  when  possible  without  touching 
the  wound  with  the  fingers,  or  to  be  quickly  poured  on  directly 
from  the  bottle. 

(/)  The  aromatic  spirits  of  ammonia  is  to  be  used  in  case  of  fainting 
or  shock. 

On  the  inside  of  the  lid  of  this  first  aid  box  the  following  legend 
is  printed  in  large  type :  (See  Fig.  77.) 

READ  CAREFULLY 

This  is  a  first  aid  outfit  only.  It  is  not  to  be  used  for  subsequent 
dressings.  The  purpose  of  the  first  aid  man  is  not  to  replace  the 
doctor.  Send  every  injured  employee  to  the  Doctor's  Office  at  once, 
no  matter  how  slight  the  injury.  Use  these  supplies  for  temporary 
dressings  until  proper  medical  care  can  be  obtained. 

DIRECTIONS 

lodin  and  Applicators. — Apply  iodin  at  once  to  all  injuries,  small  or 
large,  that  break  or  penetrate  the  skin.  Paint  over  only  once.  Do 
not  wash  injured  part  with  soap  and  water,  hydrogen  peroxid,  nor 
any  other  antiseptic.  Simply  paint  over  with  iodin.  It  kills  the  germs 
and  renders  all  dirt  in  the  wound  inactive. 

Small  Dressings. — To  cover  cuts  or  bleeding  wounds.  Remove 
tissue  paper  and  unfold  gauze.  Avoid  touching  that  portion  of  the 
dressing  which  goes  next  to  the  wound;  bandage. 

Hemorrhage  Pads. — To  be  used  on  large  wounds  or  bleeding  sur- 
faces. Unfold  the  pad  without  touching  the  surface  applied  next  to 
the  bleeding  area.  With  bandage  bind  on  sufficiently  tight  to  con- 
trol bleeding. 


500  INDUSTRIAL    MEDICINE    AND    SURGERY 

Constrictor  or  Bandage  Tourniquet. — When  severe  hemorrhage 
occurs  in  any  part  of  the  arm  or  leg  wrap  the  constrictor  about  the 
extremity  a  short  distance  above  the  point  of  hemorrhage  and  tie 
sufficiently  tight  to  control  the  bleeding. 

Aromatic  Spirits  of  Ammonia. — To  be  used  in  case  of  fainting 
or  shock.  One-half  teaspoonful  in  one-half  glass  of  water  and  give  to 
patient  to  drink,  or  let  the  patient  inhale  the  fumes  from  the  bottle. 
In  case  of  fainting  lay  person  flat  on  back  either  on  the  floor  or  on  a 
table  until  the  faint  is  over. 

5.  In  every  department  where  accident  hazards  exist,  two  or  more 
intelligent  employees  must  be  trained  in  the  following  first  aid  methods : 

(a)  To  Prevent  Infections. — lodin  is  to  be  applied  immediately  to 
every  open  wound  as  already  described.  Foreign  bodies  are 
only  to  be  removed  when  the  same  can  be  done  without  in- 
serting the  finger  into  the  wound.  The  proper  sized  sterile 
dressing  is  then  removed  from  the  tissue  paper  covering  and 
applied  to  the  wound  without  touching  the  inner  side,  which 
goes  next  to  the  wound,  with  the  fingers.  The  dressing  is  to  be 
held  in  place  by  a  bandage  or  by  adhesive  plaster.  Care  must 
be  observed  at  all  times  not  to  unduly  move  the  injured  part. 
Washing  with  soap  and  water  or  other  manipulation  of  the 
wound  is  absolutely  prohibited  at  all  times.  In  case  of  a 
compound  fracture  (a  broken  bone  accompanied  by  an  open 
wound)  the  wound  is  simply  to  be  covered  with  iodin  and  a 
sterile  dressing  applied.  Leave  manipulation  for  the  surgeon 
when  he  arrives.  In  wounds  about  the  eyes  exercise  great 
care  to  prevent  the  iodin  entering  the  eye. 

(h)  Checking  Hemorrhage. — In  case  of  excessive  bleeding  from  a 
wound  a  hemorrhage  pad  is  to  be  applied  without  touching 
the  surface  next  to  the  wound  and  the  bleeding  is  then  to  be 
checked  by  a  firm  pressure  being  made  over  the  pad  with  the 
fingers.  After  two  minutes  of  strong  pressure  if  the  bleeding 
continues  apply  the  tourniquet;  if  the  pressure  has  checked 
the  hemorrhage,  bandage  the  hemorrhage  pad  snugly  in  place. 
In  applying  the  tourniquet  a  small  compress  should  be  made 
from  a  middle-sized  dressing  and  the  cotton  bandage,  marked 
for  hemorrhages,  should  be  bound  about  the  member  as  tightly 
as  possible  and  tied  in  place.  All  of  these  maneuvers  must 
be  done  as  gently  as  possible.  In  case  of  hemorrhage  do 
not  administer  aromatic  spirits  of  ammonia  unless  absolutely 
necessary. 

(c)  Combating  Shock. — ^Every  seriously  injured  person  must  be 
immediately  placed  in  a  prone  position.     To  do  this  he  should 


FIRST    AID  501 

not  be  moved  any  great  distance.  Whenever  possible  he 
must  be  protected  from  extremes  of  heat  and  cold,  especially 
the  latter.  He  must  also  be  protected  from  a  damp  ground 
or  a  cold  cement  floor.  If  he  cannot  be  moved  to  a  dry,  warm 
spot,  then  several  coats  should  be  placed  under  him.  All 
of  the  body,  except  the  wounded  part  should  be  immediately 
covered  by  blankets  or  overcoats.  The  head  must  be  on  the 
same  level  with  the  rest  of  the  body  except  in  case  of  hemor- 
rhage or  fainting,  when  it  should  be  at  a  lower  level.  In  the 
case  of  shock  these  precautions  must  be  doubly  observed.  Heat 
should  be  applied  about  the  body.  This  can  be  done  by 
filling  dinner  pails,  bottles  or  jars  with  hot  water  or  by  the 
use  of  hot  water  bottles  or  hot  bricks  placed  near  the  body 
under  the  coverings.  Precautions  must  always  be  taken 
not  to  burn  the  patient.  Half  a  teaspoonful  of  aromatic 
spirits  of  ammonia  in  a  half  a  glass  of  water  should  be  given 
at  once  if  patient  is  conscious.  Never  give  an  unconscious 
person  water  or  other  liquid  as  it  may  enter  his  windpipe  and 
strangle  him.  If  conscious  give  the  patient  all  the  water  he 
wants  in  small  amounts  at  frequent  intervals.  In  case  of  vomit- 
ing turn  the  head  to  one  side  so  that  he  will  not  swallow  the 
vomited  matter  and  strangle  himself.  Loosen  all  tight  clothing. 
Avoid  undue  movement  of  the  body.  Do  only  what  is  neces- 
sary to  make  him  comfortable  and  keep  him  warm. 
(d)  Resuscitation. — To  be  used  in  cases  of  electric  shock,  suffocation 
or  asphyxiation  or  other  conditions  which  have  apparently 
caused  cessation  of  breathing.  Artificial  respiration  by  the 
Schdfer  or  prone  method  should  be  employed  as  follows:  Place 
the  person  on  his  abdomen;  remove  from  his  mouth  all  foreign 
bodies,  such  as  false  teeth,  tobacco  and  gum;  pull  and  keep 
the  tongue  forward;  turn  his  head  to  one  side  and  rest  it  on 
his  forearm,  so  that  the  mouth  and  the  nose  will  not  come  in 
contact  with  the  ground  and  extend  the  other  arm  forward. 
If  the  person  is  thin  prepare  a  pad  of  folded  clothing,  blankets, 
or  other  material  and  place  it  under  the  lower  part  of  his  chest. 
Do  not  make  this  pad  too  thick.  Do  not  wait  to  loosen  the 
victim's  clothing  but  begin  artificial  respiration  without 
delay.  An  assistant  may  remove  all  tight  clothing  from  the 
victim's  neck,  chest  and  waist;  blankets,  hot  water  bottles, 
safety  lamps,  or  hot  bricks  well  wrapped  in  paper  or  cloth 
should  be  placed  about  the  person  by  an  assistant.  Kneel, 
straddHng  the  person's  thighs  and,  facing  his  head,  rest  the 
palms  of  your  hands  on  his  loins — on  the  muscles  of  the  small 
of  his  back — with  your  thumbs  nearly  touching  each  other 


502  INDUSTRIAL    MEDICINE    AND    SURGERY 

and  your  fingers  spread  over  his  lowest  ribs;  with  arms  held 
straight  swing  forward  slowly  so  that  the  weight  of  your  body 
is  gradually  brought  to  bear  on  the  person.  This  operation, 
which  should  take  three  or  four  seconds,  must  not  be  violent, 
lest  the  internal  organs  be  injured.  The  lower  part  of  the 
chest  and  also  the  abdomen  are  thus  compressed  and  air  is 
forced  out  of  the  lungs.  Now,  immediately  swing  back  slowly 
so  as  to  remove  the  pressure,  but  leave  your  hands  in  place, 
thus  returning  to  the  original  position.  Through  their  elas- 
ticity the  patient's  chest  walls  expand  and  his  lungs  are  thus 
supplied  with  fresh  air.  After  two  seconds  swing  forward 
again  and  repeat  deliberately,  16  to  18  times  a  minute,  the 
double  movement  of  compressing  and  releasing — causing  a 
complete  respiration  in  about  four  seconds.  If  a  watch  or 
clock  is  not  available,  follow  the  natural  rate  of  your  own  deep 
breathing,  swinging  forward  with  each  expiration  and  back- 
ward with  each  inspiration.  Continue  artificial  respiration,  if 
necessary,  for  at  least  three  hours  without  interruption  until 
natural  breathing  has  been  restored,  or  until  a  physician  arrives. 
Even  after  natural  breathing  begins  carefully  watch  that  it 
continues.  If  it  stops,  start  artificial  respiration  again.  Do 
not  give  aromatic  spirits  of  ammonia  or  other  liquids  by 
mouth  until  the  patient  is  fully  conscious.  Keep  all  by- 
standers away  from  the  patient  in  order  to  give  him  plenty 
of  air.  (Various  machines  to  assist  or  compel  artificial  respir- 
ation have  been  invented.  Only  an  expert  in  the  manipulation 
of  such  a  machine  should  be  allowed  to  use  them.) 

(e)  Fractures. — In  case  of  fractures  never  move  the  patient, 
unless  it  is  to  free  him  from  further  danger,  until  the  part 
has  been  thoroughly  immobilized  with  a  splint.  The  injured 
limb  should  be  immobilized  with  the  least  manipulation 
possible.  A  sphnt  can  be  made  by  using  a  thin  board  slightly 
wider  than  the  injured  member  and  covering  it  with  one  or  two 
of  the  hemorrhage  pads.  It  is  then  firmly  bound  to  the 
member  with  one  or  more  of  the  cotton  bandages.  These 
same  principles  hold  in  the  case  of  dislocations.  Leave  the 
manipulation  of  the  broken  or  dislocated  parts  to  the 
surgeon. 

(/)  Burns. — In  case  of  burns  the  patient  is  to  be  brought  as  rapidly 
as  possible  to  the  doctor's  office  or  the  doctor  immediately 
summoned  to  the  patient,  the  nature  of  the  case  always  being 
explained  in  the  summons.  Cotton  rags  and  other  material 
are  not  to  be  placed  on  burns.  If  the  patient  is  in  shock, 
treat  these  symptoms  until  the  doctor  arrives. 


FIRST    AID  503 

The  above  rules  and  methods  are  sufficient  for  the  first  aid  care 
of  any  injured  employee  when  a  doctor  can  be  summoned  very  shortly. 
I  wish  to  again  emphasize  the  fact  that  the  ideal  system  of  industrial 
surgery  is  based  upon  the  immediate  treatment  of  a  wound  by  a 
qualified  surgeon. 

A  few  years  ago  no  one  question  in  accident  surgery  caused  more 
discussion  than  the  application  of  proper  antiseptic  to  an  open  wound. 
Many  good  surgeons  decried  the  use  of  any  antiseptic  and  advocated 
thoroughly  washing  with  soap  and  water.  Some  instructed  their  first 
aid  assistants  to  immediately  wash  a  wound  with  hot  water  and  soap. 
Such  a  method  is  no  longer  recommended  as  a  first  aid  procedure  and 
very  few  surgeons  to-day  apply  soap  and  water  to  any  wound.  The 
danger  of  grinding  infected  material  deeper  into  the  injured  parts  by 
such  a  washing  process  is  greater  than  if  the  wound  was  left  absolutely 
alone.  The  pendulum  then  swung  to  the  other  extreme  and  it  was 
advocated  to  thoroughly  wash  the  wound  with  bichlorid  of  mercury 
or  hydrogen  peroxid  and  then  paint  it  with  carbolic  acid,  followed  by 
alcohol.  It  is  still  a  common  sight  to  see  a  wound  washed,  anti- 
septicized  and  otherwise  picked  at  for  ten  or  fifteen  minutes  before 
the  dressing  is  applied.  Even  then  the  dressing  may  be  frequently 
soaked  with  bichlorid  or  some  other  antiseptic. 

The  replies  to  the  questionnaire  sent  out  by  the  Committee  on 
Standardization  of  First  Aid  Methods,  as  well  as  the  investigations 
of  Dr.  Bloodgood,  show  that  at  least  90  per  cent,  of  the  surgeons  in 
industry  advocate  the  use  of  some  antiseptic  as  a  first  aid  measure. 
Approximately  80  per  cent,  of  these  advocate  tincture  of  iodin  as  the 
best  and  most  logical  antiseptic  to  be  used.  The  majority  of  these  are 
in  favor  of  the  patient,  or  a  fellow  workman,  painting  the  part  at 
once  with  tincture  of  iodin,  but  some  of  these  surgeons  fear  that  such 
a  procedure  gives  a  false  security  to  the  employee  and  lessens  the 
chances  of  his  reporting  to  the  doctor  for  proper  treatment. 

My  own  experience  has  absolutely  convinced  me  that  the  immediate 
use  of  tincture  of  iodin  to  an  injured  part  by  the  employee  himself 
or  by  a  fellow  employee  is  the  most  important  first  aid  procedure  which 
can  be  adopted  in  industry.  In  1909,  when  I  first  used  iodin  in  every 
department  of  the  industry  with  which  I  was  connected,  there  was 
an  immediate  reduction  of  28  per  cent,  in  the  number  of  infections 
the  first  month  after  this  plan  was  installed.  To  counteract  the  danger 
of  the  injured  employee  thinking  that  the  use  of  iodin  was  all-sufficient, 
bulletins,  letters  and  constant  warnings  were  scattered  throughout 
the  working  forces  to  the  effect  that  "Every  injury — no  matter  how 
shght — must  be  painted  with  iodin  at  once  and  then  the  employee 
must  report  to  the  doctor  immediately."  Some  claim  that  the  report- 
ing to  the  doctor  at  once  is  sufficient.     Every  year,  however,  has  more 


504 


INDUSTRIAL    MEDICINE    AND    SURGERY 


clearly  demonstrated  that  the  combination  of  the  use  of  iodin  and  the 
reporting  to  the  doctor  at  once  is  superior  to  the  method  of  only 
reporting  to  the  doctor  at  once.  The  nature  of  the  work  in  this  in- 
dustry was  such  as  to  cause  a  great  many  minor  accidents  from  such 
conditions  as  pin  pricks,  nail  wounds,  slivers,  abrasions,  etc.  The 
following  table  clearly  demonstrates  that  the  double  procedure  gives 
better  results  than  the  single  method  of  reporting  at  once : 

Table    17 

TABLE  ILLUSTRATING  THE  VALUE  OF  "USE  OF  IODIN  AT  ONCE 
AND  REPORTING  TO  THE  DOCTOR  AT  ONCE" 


Total  number  of  infections 

ilodin  used  in  Dept.  reported  at  once 

1  Iodin  not  used  in  Dept.  reported  at  once. 

Rules  not  observed 


1913 


710 

18 

28 

668 


655 

16 

28 

611 


586 

5 
12 

569 


1916 


610 

10 
12 

588 


The  degree  of  infection  in  those  cases  where  iodin  was  used  or 
where  they  reported  to  the  doctor's  office  was  very  slight  and 
consisted  only  of  redness  and  a  small  degree  of  swelling  about  the  wound 
or  a  drop  of  pus.  The  fact  that  none  of  these  lost  time  from  work 
or  required  an  incision  clearly  points  to  very  mild  infection. 

The  large  number  of  infected  cases  that  failed  to  observe  these 
rules  came  from  the  following  groups : 

(a)  New  employees  who  had  not  yet  learned  their  lesson  (one 
year  80  per  cent,  of  the  infected  cases  came  from  this  group). 

(&)  Employees  who  failed  to  report  to  work  and  who  could  not 
be  located  by  the  visiting  nurse,  and  otherwise  neglected  their  dressings. 

(c)  Employees  who  removed  their  dressings  at  home  and  applied 
some  home  remedy. 

(d)  The  employee  who  "didn't  believe  in  doctors." 

(e)  Christian  scientists. 

Such  figures  plainly  show  that  no  matter  how  extensive  your 
preventive  measures  are,  or  how  extensive  an  educational  campaign 
you  wage,  these  careless  employees  will  always  be  a  source  of  trouble. 

During  these  four  years  there  were  39,672  accidents  cared  for  in 
this  industry.  These  include  the  infected  cases  shown  in  the  foregoing 
table.  Out  of  this  total  number  of  accident  cases,  even  including  the 
very  serious  crushing  and  mutilating  wounds,  where  the  employees 
observed  the  first  aid  rules  and  continued  under  the  constant  care  of 
the  plant  surgeon  the  infection  rate  was  only  1.2  per  cent. 

1  None  of  these  required  incision  nor  lost  time  from  work. 


FIRST    AID  505 

Bloodgood,  as  a  result  of  his  investigations  concerning  the  various 
methods  used  by  several  hundred  industrial  surgeons,  summarizes  his 
conclusions  concerning  various  uses  of  a  first  aid  antiseptic  by  saying: 
"As  far  as  can  be  ascertained  from  the  industries  the  answer  is 
practically  uniform:  that  an  antiseptic  is  of  immense  value  in  the 
wounds  in  industry  in  preventing  infection.  Whether  that  antiseptic 
should  be  applied  by  the  individual  or  by  the  doctor  who  sees  the 
wound  quickly  is  a  question  on  which  I  can  get  very  little  evidence. 
The  great  majority  of  surgeons  in  industries,  however,  agree  that 
iodin  is  the  best  antiseptic  to  be  used." 

Many  of  our  best  industrial  surgeons  advocate  a  much  mxore 
extensive  system  of  first  aid  than  that  outlined  by  the  author.  This 
is  partly  due  to  the  fact  that  these  doctors  have  fewer  assistants  so 
that  it  is  impossible  for  a  physician  to  always  render  the  emergency 
treatment  at  once;  or  because  the  employees  are  so  scattered  that 
fifteen  minutes  to  one  or  two  hours  must  elapse  before  it  is  possible 
for  the  doctor  to  see  the  patient.  Naturally,  under  these  conditions, 
they  must  depend  more  upon  lay  assistants.  Bear  in  mind,  however, 
that  even  these  reasons  are  not  sufficient  to  permit  of  too  much  leeway 
being  given  to  the  first  aid  man. 

Doctor  Loyal  Shoudy  of  the  Bethlehem  Steel  Company  has 
developed  a  very  excellent  first  aid  system,  which  is  constantly 
supervised  by  the  doctor  and  his  assistants.  This  consists  of  teams 
of  six  or  eight  men,  who  are  thoroughly  trained  in  a  great  many 
different  first  aid  methods.  Every  large  department  has  its  team.  He 
has  extended  this  system  to  include  not  only  the  home  plant  but  all 
of  the  subsidiary  organizations.  In  order  to  stimulate  enthusiasm 
and  expertness  among  the  various  first  aid  teams  he  holds  an  annual 
First  Aid  Meet.  The  teams  enter  intensive  training  for  several  weeks, 
solving  many  theoretical  problems  of  first  aid  care  to  the  injured.  A 
preliminary  interdepartmental  first  aid  meet  is  held  and  the  winning 
teams  then  represent  the  various  plants  at  the  final  meet.  The  prob- 
lems for  the  contest  are  selected  from  the  records  of  actual  injuries 
which  the  various  first  aid  teams  attended  during  the  preceding  year. 
In  the  recent  first  aid  meet  held  at  Bethlehem  the  following  problems 
were  selected  for  execution  by  the  contesting  teams: 

1.  Dress  compound  fractures  of  leg,  L.,  lower  third,  splints.  Eight 
triangular  bandages.  One  tourniquet.  One  dressing.  Use  im- 
provised stretcher.     Blanket.     Time  Allowance  10  minutes. 

2.  Dress  fracture  of  knee  cap,  R.,  crush  of  foot,  R.,  and  laceration 
of  scalp.  Two  splints.  Eight  triangular  bandages.  Two  dressings. 
Time  allowance  8  minutes. 

3.  Dress  hums  of  foot,  R.,     calf  of  same  leg,  fracture  of  lower  jaw, 


506  INDUSTRIAL   MEDICINE    AND    SURGERY 

R.,   and   laceration   of  chest,   L.     Five   triangular  bandages.     Three 
dressings.     Time  allowance  8  minutes. 

4.  Dress  dislocation  of  shoulder,  L.,  hum  of  hack  of  hand,  L.,  and 
crush  of  foot,  R.  Five  triangular  bandages.  One  piece  I"  roller  band- 
age.    Two  dressings.     One  splint.     Time  allowance  8  minutes. 

5.  Dress  fracture  of  the  hack.  Splints.  Fourteen  triangular 
bandages.     Two  blankets.     Time  allowance  10  minutes. 

6.  Dress  lacerated  shoulder,  R.,  and  opposite  fractured  forearm. 
Seven  triangular  bandages.  Two  splints.  One  dressing.  Time 
allowance  8  minutes. 

7.  Patient  found  in  unconscious  condition  from  prolonged  inhalation 
of  hlast  furnace  gas,  rescue  (one  man  method).  Resuscitate  (demon- 
strate Schafer  and  Sylvester  methods).  Two  blankets.  Stimulants. 
Time  allowance  5  minutes. 

8.  Dress  burns  of  entire  head,  face,  back,  chest,  shoulders,  and  hack 
of  both  hands.  Six  triangular  bandages.  Four  dressings.  Blanket. 
Time  allowance  8  minutes. 

9.  Dress  fracture  of  lower  jaw,  R.,  and  sprain  of  ankle,  R.  Two 
triangular  bandages.  One  2"  roller  bandage.  Time  allowance  8 
minutes. 

10.  Rescue  from  electrical  contact. 

Instructions 

Dress  the  most  serious  injury  first. 

Do  not  allow  fingers  to  come  in  contact  with  underside  of  dressings. 

Grasp  artery  and  use  tourniquet  in  all  cases  of  compound  fracture. 

Watch  for  symptoms  of  shock  in  all  injuries. 

Treat  for  shock  in  all  problems  where  blanket  is  indicated. 

In  dressing  patients,  kneel  on  knee  next  to  patient's  feet. 

While  the  above  were  theoretical  cases  arranged  for  purposes  of 
the  field  meet,  yet  they  illustrated  the  exact  nature  of  the  injuries 
which  these  first  aid  teams  were  called  upon  to  treat  during  the  course 
of  their  work.  Dr.  Shoudy's  paper  before  the  1918  Convention  of  the 
National  Safety  Council  thoroughly  explains  his  methods  of  training 
these  teams. 

There  is  no  question  but  that  better  results  could  be  obtained  if 
emergency  treatment  by  quahfied  physicians  could  be  rendered  at 
once  in  such  extensive  injuries  as  these,  but  in  the  absence  of  a  suffi- 
cient number  of  physicians  to  meet  the  situation,  this  elaborate  plan 
in  a  hazardous  industry  is  worthy  of  great  commendation. 

One  of  the  greatest  functions  of  these  teams  is  the  constant  study 
of  works  conditions  in  order  to  prevent  accidents.  It  is  very  essential 
that  every  first  aid  man  should  be  first,  last  and  all  the  time  a  preven- 
tion man. 


FIRST    AID  507 

The  N,  A.  S.  O.  First  Aid  outfit  is  the  result  of  numerous  confer- 
ences of  surgeons  from  different  industries,  held  under  the  auspices 
of  the  Conference  Board  of  Industrial  Physicians.  Dr.  Lauffer,  of 
the  Westinghouse  Company,  who  helped  standardize  this  outfit,  de- 
scribes it  as  follows:  "The  container  is  glass,  the  contents  include 
(1)  drugs  and  (2)  dressings;  and  are: 

1    tourniquet. 
1  pr.  nickel  plated  scissors. 
1  triangular  sling. 
12  assorted  safety  pins. 
1  wire  gauze  splint. 

1  two  ounce  bottle  castor  oil. 

2  three  ounce  bottles  burn  ointment. 

1  two  ounce  bottle  3  per  cent,  alcoholic  iodin. 

1  two  ounce  bottle  white  wine  vinegar. 

1  two  ounce  bottle  aromatic  spirits  of  ammonia. 

1  two  ounce  bottle  4  per  cent,  aqueous  boric  acid. 

1  two  ounce  bottle  Jamaica  ginger. 

1  piece  of  flannel  24"  X  36". 

1  roll  absorbent  cotton. 

1  roll  3"  X  10  yd.  gauze  bandage. 

2  rolls  2"  X  10  yd.  gauze  bandage. 

1  spool  1"  X  5  yd.  adhesive  plaster. 
4  rolls  1"  X  10  yd.  gauze  bandage. 
6  packages  6"  X36"  sterile  gauze. 
1  teaspoon. 

1  medicine  glass. 

2  medicine  droppers. 

3  paper  drinking  cups. 
12  first  aid  record  cards. 

11  finger  splints. 

12  wooden  applicators. 
1  instrument  box, 

1  cotton  box. 

This  detailed  list  of  contents  were  regarded  as  the  best  item^to  include 
in  the  outfit  in  the  year  1915,  in  the  collective  judgment  of  the  Con- 
ference Board. 

"The  special  requirements  of  particular  injuries  are  cared  for  by 
adding  to  or  subtracting  from  the  standard  contents  of  this  jar. 

"The  rules  of  procedure  for  the  instruction  of  laymen  were  agreed 
upon  by  the  Conference  Board  in  advance  of  the  selection  of  the  con- 
tents of  the  jar,  and  it  will  be  observed  that  the  first  aid  taught  is 
preliminary,  not  final  treatment,  and  that  it  is  designed  that  the  pa- 


508  INDUSTRIAL   MEDICINE    AND    SURGERY 

tient  be  given  reasonable  first  aid  attention,  pending  the  care  of  the 
case  by  a  physician." 

Dr.  A.  W.  Colcord,  of  the  Carnegie  Steel  Company,  is  one  of  the 
pioneers  in  the  instruction  of  the  layman  in  the  application  of  first  aid. 
He  states  "I  believe  we  have  overdone  this  work;  I  feel  that  we  have 
undertaken  to  teach  too  much  and  to  allow  the  layman  to  do  too 
much.  After  three  years  of  lecturing  to  forty  special  groups  on  this 
subject  I  have  boiled  down  instructions  on  this  subject  to  just  four 
things: 

1.  How  to  treat  hemorrhages. 

2.  How  to  treat  shock  and  asphyxia. 

3.  How  to  transport  the  injured  man  with  a  maximum  of  speed 
and  a  minimum  of  trauma  to  the  proper  place. 

4.  What  not  to  do:  To  keep  away  entirely  from  the  wound; 
not  to  administer  a  dressing;  and  get  to  the  emergency 
hospital  as  quickly  as  possible. 

I  believe  attempted  treatment  of  wounds  by  a  layman  has  done  in- 
finite harm  and  that  we  cannot  condemn  it  too  strongly." 

In  1917  the  Bureau  of  Mines,  Department  of  the  Interior  issued 
a  small  book  on  "First  Aid  Instructions  for  Miners;  a  Report  on 
Standardization.  This  was  compiled  by  a  Committee  of  surgeons 
consisting  of  G.  H.  Halberstadt,  A.  F.  Knoefel,  W.  A.  Lynott,  W.  S. 
Rountree  and  M.  J.  Shields.  Every  surgeon  in  industry  should  read 
this  book  as  it  is  pregnant  with  excellent  ideas,  not  only  on  first  aid 
care  but  on  emergency  surgical  treatment.  The  following  summary 
shows  the  extent  of  the  first  aid  work  advocated  by  these  authorities 
for  mine  employees: 

FIRST  AID  EQUIPMENT 
(Surface  First  Aid  Dressing  Station) 

"At  a  suitable  place  on  the  surface  and  near  the  mine  opening 
there  should  be  a  first  aid  dressing  station,  which  also  can  be  used  as 
a  storeroom  for  first  aid  suppHes.  In  this  building  should  be  a 
stretcher,  woolen  blanket,  waterproof  blanket,  and  sphnts,  all  of  which 
except  the  splints  should  be  suitably  protected  from  moisture  and  air 
in  a  sealed  tin  case,  or  its  equivalent.  Also  there  should  be  first  aid 
packets  in  germ  proof  and  waterproof  wrappings  suitably  protected 
in  sealed  metal  boxes,  and  first  aid  cabinets. 

Contents  of  First  Aid  Cabinet 

"Each  cabinet  should  contain: 

12  sterile  triangular  (unprinted)  bandages. 

12  small   bandage    compresses,    each    1"   square   when  folded 

upon  itself  about  15  times,  with  mushn  tails  }i  yard  long, 

the  center  being  sewed  to  compress. 


FIRST    AID  509 

12  medium-size  bandage  compresses,  each  2^'^"  square  when 

folded  upon  itself  about  18  times,  with  muslin  tails  1  yard 

long,  the  center  being  sewed  to  compress. 
6  large   bandage   compresses,    each   33^^"   square   and  folded 

upon  itself  about  20  times,  with  muslin  tails  2  yards  long, 

the  center  being  sewed  to  compress. 
6  packages   of   sterile   picric  acid    gauze,   each   containing  a 

piece  of  gauze  1  yard  square. 
6  yucca  splints  or  similar  material. 
1  two  ounce  bottle  aromatic  spirits  of  ammonia. 
6  paper  cups. 
1  teaspoon  (horn). 
1  tourniquet. 
1  pair  of  scissors. 

(From  First  Aid  Instructions  for  Miners.) 

Underground  Dressing  Stations 
"  First  aid  dressing  stations  should  be  maintained  near  the  bottom 
of  the  shaft  or  slope  and  at  a  central  sidetrack.  One  first  aid  cabinet 
should  be  available  for  every  100  men  or  less.  At  least  one  man  out 
of  every  10  employees  should  carry  a  first  aid  packet  which  should 
be  refilled  when  necessary. 

Surface  Hospital  Room 
"  Where  a  large  number  of  men  are  employed,  there  should  be  avail- 
able on  the  surface  a  room  provided  with  suitable  hospital  facilities, 
and  having  a  surgeon  in  attendance.  The  building  should  be  as  close 
to  the  entrance  of  the  mine  as  possible  and  should  be  supplied  with 
the  necessary  articles,  all  furniture  and  utensils,  except  perhaps  the 
chairs,  to  be  covered  with  heavy  white  enamel. " 

Suggestions 

The  authors  of  this  report  make  the  following  suggestions : 

"1.  That  as  far  as  possible  first  aid  training  be  given  under  the 
immediate  supervision  of  a  regularly  registered  and  qualified  physician. 

"2.  That  there  be  close  co-operation  with  the  first  aid  department 
of  the  American  National  Red  Cross  in  first  aid  work. 

''3.  That  all  examinations  for  first  aid  certificates  be  held  by  a 
qualified  physician  and  conform  with  such  standards  as  may  be  laid 
down  by  the  Bureau  of  Mines. 

"4.  That  it  be  an  imperative  rule  that  in  all  first  aid  contests  the 
judges  shall  be  regularly  qualified  physicians  trained  in  first  aid  work. 

"5.  That  where  it  is  possible  every  employee  in  a  mine  be  trained 
in  first  aid  work  but  if  this  is  impossible  that  at  least  1  out  of  every 
10  employees,  both  underground  and  on  the  surface,  receive  such 
training." 


510  INDUSTRIAL    MEDICINE    AND    SURGERY 

CONCLUSIONS 

This  chapter  on  first  aid  clearly  indicates  that  the  question  as 
to  what  extent  laymen  should  be  permitted  to  treat  injured  employees 
is  still  unsettled.  Practically  every  worker  in  this  field  agrees  that 
a  certain  amount  of  first  aid  care  is  necessary.  They  further  agree 
that  the  extent  and  method  of  first  aid  care  should  be  standardized. 

The  war  interfered  with  the  work  of  standardization,  undertaken 
by  the  American  Association  of  Industrial  Physicians  and  Surgeons 
and  also  by  the  Committee  on  Standardization  of  the  U.  S.  Public 
Health  Service.  It  is  hoped  that  these  two  organizations  will  get 
together  as  soon  as  the  present  emergency  permits  and  work  out  this 
standardization. 

The  author  believes  that  all  first  aid  methods  should  include  and 
be  limited  to  the  following: 

1.  The  immediate  application  of  tincture  of  iodin  to  all  open 
wounds. 

2.  The  appointment  of  a  responsible  person  among  each  group  of 
employees  to  see  that  the  injured  employee  reports  to  the  doctor  at 
once. 

3.  The  instruction  of  two  or  more  responsible  persons  among 
each  group  of  100  employees  in  the  best  first  aid  methods  of 

(a)  Controlling  hemorrhages. 
(6)  Combating  shock. 

(c)  Resuscitation  by  artificial  respiration. 

(d)  Immobilization  of  fractures. 

(e)  Transporting  the  injured  when  necessary 

Every  report  on  this  subject  should  point  out  most  emphatically 
the  importance  of  having  a  qualified  surgeon  on  the  job  in  industry 
at  all  times  in  order  to  render  immediate  emergency  treatment. 


CHAPTER  XXXIII 
EMERGENCY  SURGERY 

Emergency  surgery  is  the  first  treatment  rendered  to  an  injured 
person  by  the  surgeon.  An  emergency  operation  is  one  performed  to 
relieve  some  sudden  emergency  as,  for  example,  the  opening  of  an 
abdomen  to  relieve  a  hemorrhage  or  a  tracheotomy  performed  because 
of  a  foreign  body  blocking  the  larnyx. 

As  used  in  industrial  surgery  first  aid  is  rendered  by  a  layman  but 
emergency  surgery  is  always  rendered  by  the  surgeon.  On  the  battle- 
field and  in  some  industries  the  expert  first  aid  man  has  been  so  well 
trained  in  his  work  that  often  the  first  aid  treatment  rendered  by 
him  is  sufficient.  Col.  Frank  Billings,  reporting  on  the  work  which  he 
saw  at  the  front  in  France,  stated  that  frequently  the  enlisted  medical 
man  applied  the  splint  so  thoroughly  to  a  fractured  limb  that  it  was 
unnecessary  for  the  surgeon  to  redress  the  fracture  for  several  days. 
Dr.  Shoudy  has  found  that  quite  often  his  first  aid  men  have  executed 
their  work  so  thoroughly  that  he  was  able  to  send  the  patient  direct  to 
the  hospital  for  permanent  care,  without  giving  any  emergency  treat- 
ment. As  a  general  rule,  however,  it  would  be  a  dangerous  practice  for 
this  first  aid  care  to  replace  the  emergency  surgery  rendered  by  a  quali- 
fied surgeon. 

This  view  is  gradually  becoming  universal  and  as  a  result  surgical 
dispensaries  are  being  established  in  many  of  our  large  industries 
and  a  surgeon  is  kept  at  the  plant  at  all  times  in  order  to  render 
immediate  emergency  surgery  and  thereby  obviate  as  far  as 
possible  the  need  for  the  less  efficient  first  aid  work. 

In  fact,  well  organized  medical  staffs  within  our  industries,  with 
facilities  for  treating  injured  employees  immediately  after  the 
occurrence  of  an  accident,  have  made  first  aid  superfluous  in  the  ma j  ority 
of  instances.  These  physicians  insist  on  seeing  patients  at  once  before 
first  aid  measures  have  been  applied.  This  limits  the  need  for  trained 
first  aid  workers  to  those  departments  where  hazardous  processes  are 
carried  on  and  where  the  employees  are  so  far  removed  from  the 
dispensary  as  to  render  immediate  care  impossible.  Even  here 
the  injured  employee  and  the  surgeon  can  get  together  so  quickly  that 
emergency  surgery  is  preferable. 

The  surgical  dispensary,  its  equipment  and  the  necessary  surgical 

511 


512  INDUSTRIAL    MEDICINE    AND    SURGERY 

staff  have  been  fully  described  in  other  chapters.  (See  Chapter  XXXI.) 
Therefore  this  chapter  will  be  devoted  to  those  conditions  commonly 
arising  in  industry  which  require  emergency  treatment  and  to  a 
description  of  the  practical  methods  which  have  been  found  most 
efficacious  under  the  different  circumstances. 

Two  great .  slogans  have  developed  in  connection  with  accident 
surgery  in  industry.  One  deals  with  prevention  in  the  pre-accident 
stage  and  is  known  as  '^safety  first;"  the  other  deals  with  the  post- 
accident  stage  and  is  represented  by  "report  at  once."  This  reporting 
to  the  doctor  at  once  when  an  injury  is  received,  always  qualified  by 
''no  matter  how  slight"  is  the  universal  preventive  measure  adopted 
by  all  surgeons  in  industry.  As  a  result  the  great  proportion  of  their 
work  consists  of  the  emergency  treatment  of  minor  accidents  and  their 
subsequent  dressings. 

In  the  author's  experience  a  hundred  of  these  minor  cases  report  to 
the  doctor's  office  for  every  five  of  the  more  seriously  injured  em- 
ployees. In  the  combined  major  and  minor  accidents  about  one 
injury  out  of  twelve  is  sufficiently  disabling  as  to  require  actual 
lost  time  from  work,  providing  the  injured  parties'  report  at  once 
to  the  doctor.  Approximately  one  of  these  disabling  accidents 
out  of  every  fifteen  causes  a  disability  exceeding  fourteen  days. 
In  the  major  accidents,  fractures  are  the  chief  cause  of  dis- 
ability, averaging  42.8  days  per  case.  Sprains  and  dislocations  were 
second  and  hernias  came  third  in  this  class  of  accidents  causing  the 
greatest  amount  of  disability.  Thus,  in  major  accidents,  the  cause 
of  disability  can  usually  be  traced  to  the  severity  of  the  injury  as 
these  employees  are  under  control  and  therefore  their  treatment  is 
uninterrupted.  The  greatest  cause  for  disability  among  the  minor  acci- 
dent cases  was  infection.  These  occurred  commonly  among  two  classes, 
namely,  those  who  failed  to  report  to  the  doctor  at  once  and  those  who 
were  careless  about  their  dressings  or  their  return  visits.  Thus  the 
majority  of  disability  cases  in  this  class  can  be  traced  to  carelessness 
and  neglect  on  the  part  of  the  patient. 

Accidents  in  the  general  industries  involve  chiefly,  the  fingers  and 
hands,  the  toes  and  feet,  the  eyes,  the  lower  extremities,  upper  extremi- 
ties, the  back,  the  head  and  the  abdomen,  named  in  their  order  of 
frequency. 

The  most  frequent  minor  wounds  are: (a)  abrasions;  (b)  contusions; 
(c)  lacerations;  (d)  puncture  wounds;  (e)  blisters;  (/)  brush-burns; 
(g)  foreign  bodies  in  the  eye;  (h)  foreign  bodies  penetrating  the  soft 
parts;  (?')  strains;  (j)  sprains;  (k)  tenosynovitis;  (I)  swallowing  foreign 
objects. 

Complications  oftenest  arising  from  these  wounds  are  infections, 
ulcers,  keloids  and  scar  contractures. 


EMERGENCY    SURGERY  513 

The  chief  major  wounds  met  with  in  accident  surgery  are:  (a) 
fractures;  (6)  crushing  wounds;  (c)  dislocations;  (d)  penetrating  wounds; 
(e)  burns;  (/)  loss  of  members;  (g)  avulsions;  (h)  injuries  of  nerves, 
blood-vessels  and  viscera;  (i)  brain  injuries;  (j)  special  traumas,  as 
traumatic  hernias,  traumatic  orchitis,  traumatic  pleurisy,  traumatic 
appendicitis  and  traumatic  neuroses.  These  severe  wounds  may  have 
any  one  of  the  complications  common  to  minor  injuries  and  in  addition 
the  immediate  complications  of  shock  and  hemorrhage,  and  the  more 
remote  complications  represented  by  systemic  conditions  occurring 
as  the  result  of  lowered  resistance.  Naturally  permanent  deformities 
more  frequently  follow  these  major  accidents. 

Every  variety  and  degree  of  the  above  minor  and  major  injuries 
may  occur  singly  or  in  combination  and  any  one  or  several  regions 
of  the  body  may  be  involved.  The  complications  which  may  arise 
are  so  numerous  and  often  so  surprising  in  their  occurrence  that  the 
alertness  and  skill  of  the  surgeon  is  taxed  to  the  utmost.  No  field 
of  surgery  is  more  varied,  and  therefore  more  interesting,  than  this 
accident  work. 

In  addition  to  the  above,  emergency  surgery  in  industry  must 
contend  with  certain  conditions  not  causing  visible  wounds  but  which 
nevertheless  are  injuries  resulting  in  the  course  of  employment. 
These  include  such  cases  as  suffocation,  asphyxiation,  acute  poisoning, 
freezing,  heat  stroke  and  sun  stroke. 

The  emergency  care  of  any  of  these  accidental  conditions  involves 
in  every  case  consideration  of  a  logical  sequence  of  treatment : 

1.  Prevent  complications. 

2.  Combat  immediate  complications. 

3.  Temporary  or  permanent  relief. 

4.  Apply  dressings. 

In  95  per  cent,  of  injured  cases  the  line  of  treatment  can  follow 
the  above  sequence  and  the  expert  emergency  surgeon  automatically 
considers  each  of  these  steps  in  turn.  However,  in  a  small  number 
of  cases  he  is  forced  to  forget  every  other  step  and  exert  all  his  energies 
.toward  combating  the  worst  complication:  impending  death.  There- 
fore, in  5  per  cent,  of  the  cases,  steps  one  and  two  may  be  forced  to 
exchange  places  in  the  sequence  of  treatment. 

PREVENT  COMPLICATIONS 

Infections. — In  all  accident  surgery  the  commonest  and  most 
feared  complication  is  infection.  In  its  wake  follows  many  other 
complications,  notably  deformities,  loss  of  members,  systemic  diseases 
and  even  death.  The  prevention  of  infections  is  the  earliest  lesson 
learned  by  the  surgeon  in  industry.     The  majority  of  these  surgeons 

33 


514  INDUSTRIAL    MEDICINE    AND    SURGERY 

have  learned  by  experience  that  the  best  methods  of  prevention  consist 
of  three  things: 

(a)   Immediate  application  of  an  antiseptic  to  an  open  wound. 

(h)  The  earliest  possible  treatment  of  the  wound  by  a  qualified 
physician. 

(c)  Protection  of  the  wound  by  sterile  dressings;  regular  and 
uninterrupted  care  until  healed. 

Surgeons  may  differ  as  to  the  kind  of  antiseptic,  or  regarding  some 
minor  points  in  the  treatment,  or  as  to  the  type  of  dressing  to  employ 
and  the  frequency  of  redressings,  but  no  experienced  worker  in  this 
field  differs  as  to  the  prime  importance  of  these  three  steps  in  prevent- 
ing infections. 

From  a  careful  investigation  of  the  kind  of  antiseptic  used  in 
accident  surgery  it  is  safe  to  say  that  at  least  80  per  cent,  of  the  surgeons 
use  some  form  of  tincture  of  iodin.  In  the  chapter  on  First  Aid  and 
again  in  the  chapter  on  Hand  Infections  the  author  has  advanced  the 
strongest  arguments  in  favor  of  the  efficacy  of  tincture  of  iodin  as  a 
preventive  agent.  The  fact  that  it  is  used  so  universally  by  the 
majority  of  surgeons  is  only  another  argument  in  favor  of  it  as  the 
antiseptic  of  choice  in  emergency  surgery. 

The  strength  of  the  tincture  of  iodin  advocated  varies  from  3  per 
cent,  to  the  10  per  cent,  tincture.  The  majority  seem  to  use  a  5 
per  cent,  strength  diluted  with  alcohol.  Some  have  urged  the  use 
of  glycerin  with  iodin  (one  part  of  glycerin,  three  parts  of  iodin) 
as  a  means  of  preventing  irritation  of  the  skin  or  the  severe  burning 
complained  of  by  many  patients  when  the  application  of  iodin  to  a  raw 
wound  is  made. 

The  antiseptic  should  be  applied  to  the  open  wound  as  soon  after  the 
injury  is  received  as  possible.  In  order  to  meet  this  requirement, 
tincture  of  iodin  with  applicators  should  be  kept  at  regular  stations 
throughout  the  working  place  where  the  injured  party  or  some  fellow 
employee  can  apply  it  at  once  to  the  injured  surface.  This  method 
is  fully  described  elsewhere.  Iodin  can  be  applied  by  cotton  apphca- 
tors,  by  pouring  on  the  wound,  by  applying  with  a  camel's  hair  brush, 
or  by  using  some  of  the  commercial  tubes  which  are  so  made  that  the 
iodin  exudes  through  a  gauze  stopper,  making  combination  container 
and  applicator.  Another  excellent  commercial  tube  on  the  market 
is  sealed  with  paraffin,  the  tip  of  which  can  be  broken  off  allowing 
the  iodin  to  escape  slowly.  After  using  it  the  opening  in  the  paraffin 
can  be  sealed  by  heating  with  a  match.  I  have  not  found  these 
commercial  tubes  as  practicable,  however,  as  iodin  and  applicator, 
chiefly  because  in  large  wounds  one  desires  to  quickly  pour  the  iodin 
over  the  surface.  When  employees  are  allowed  to  use  the  iodin  them- 
selves they  should  be  warned  against  rubbing  great  quantities  of  the 


EMERGENCY    SURGERY  515 

antiseptic  into  the  skin  or  against  .soaking  a  dressing  or  cotton  with  it 
and  binding  same  on  the  wound.  The  only  cases  of  burning  of  the 
skin  which  the  author  has  noted  have  been  in  the  few  instances  where 
excessive  amounts  of  the  iodin  have  been  used  in  this  way.  This  use 
of  the  iodin  in  the  departments  by  the  employees  has  not  caused  them 
to  cease  reporting  to  the  doctor  at  once  for  minor  injuries,  an  argument 
which  is  often  advanced  against  this  system.  When  the  patient 
reports  to  the  dispensary,  even  though  iodin  has  been  applied 
in  the  department,  the  surgeon  should  again  apply  the  antiseptic, 
making  sure  that  every  portion  of  the  wound  is  treated.  In  the 
severer  injuries  this  will  often  be  very  painful  but  the  momentary 
pain  is  much  better  than  the  prolonged  suffering  following  a  later  in- 
fection. Where  active  bleeding  is  present,  this  should  be  stopped 
by  pressure  with  sterile  gauze  before  the  iodin  is  applied  in  order  to  be 
assured  that  the  bottom  of  the  wound  is  reached.  The  application 
of  this  antiseptic  should  be  done  quickly  and  deftly  and  nothing  is 
gained  by  subjecting  the  patient  to  repeated  applications.  However, 
in  severe  crushing  wounds  a  second  treatment  with  the  iodin  should 
be  made  after  the  patient  is  anesthetized  and  before  any  operative 
procedure  is  undertaken. 

Other  antiseptics  used  on  wounds  for  the  prevention  of  infection 
include  carbolic  acid  followed  by  alcohol,  alcohol  alone,  bichlorid  of 
mercury  (1  to  1000),  hydrogen  peroxid,  turpentine,  salt  solution  and 
recently  Dakin's  solution  or  some  modification  of  it  and  dichloramin- 
T.  Carbolic  acid  is  not  a  safe  routine  antiseptic  to  use  and  really  is 
only  indicated  in  bites  or  other  places  where  cauterization  is  needed. 
Its  use  should  be  followed  by  alcohol.  Bichlorid  of  mercury  was  for- 
merly used  quite  extensively  in  emergency  surgery  but  nevet  accom- 
plished the  desired  result  as  tincture  of  iodin  has  done.  Hydrogen 
peroxid  is  of  very  little  value  as  an  antiseptic  for  the  prevention  of 
infections;  in  fact  in  wounds  with  small  external  openings  the  forceful 
expansion  of  the  peroxid  may  carry  foreign  infected  material  deeper 
into  the  wound.  Turpentine  has  been  commonly  used  by  employees 
themselves  to  prevent  blood  poisoning.  It  is  very  painful  and  not 
as  efficacious  as  iodin.  Since  war  surgery  has  demonstrated  the 
value  of  Dakin's  solution  and  dichloramin-T  a  few  surgeons  have 
adopted  the  use  of  these  as  preventive  antiseptics  in  lieu  of  iodin. 
Dr.  Lee  feels  that  the  immediate  application  of  dichloramin-T  would 
prevent  all  infections  and  would  be  a  cheaper  antiseptic  than  iodin. 
Experimentation  is  now  being  conducted  to  prove  whether  or  not 
this  is  true.  Some  surgeons  have  advocated  the  use  of  Dakin's 
solution  in  the  same  way  and  often  give  their  patients  a  bottle  of  this 
solution  to  pour  on  the  dressings  covering  the  wound  at  stated  inter- 
vals.    More   actual  experience  is  necessary  before  either  of  these 


516  INDUSTRIAL    MEDICINE    AND    SURGERY 

methods  can  be  recommended  and  certainly  before  many  surgeons 
would  be  willing  to  discard  their  old  standby,  tincture  of  iodin.  One 
of  the  strongest  exponents  of  this  new  antiseptic  reported  two  years 
ago  77,000  wounds  treated  by  the  old  methods  with  only  90  infections, 
while  one  of  his  colleagues  reported  3500  wounds  treated  by  the  old 
methods  with  no  infections.  They  are  now  using  Dakin's  solution 
and  claim  that  it  is  producing  splendid  results.  Certainly  it  would  be 
hard  to  conceive  of  any  better  results  in  accident  surgery  than  those 
reported  by  these  two  men  when  using  the  tincture  of  iodin. 

It  is  interesting  to  read  of  the  different  antiseptics  advocated  by 
the  various  surgeons  operating  at  the  front  in  this  war.  The  English 
speak  first  of  carbolic  acid  or  diluted  carbolic  acid,  while  the  French 
extol  iodin.  After  a  year  or  two  of  the  war,  Wright,  the  English 
surgeon,  urged  the  use  of  salt  solution  while  Carrel,  operating  with  the 
French,  proclaimed  Dakin's  solution  as  the  antiseptic  of  choice.  In 
the  fourth  year  of  the  war  many  surgeons  have  swung  back  to  the 
use  of  tincture  of  iodin  as  the  best  emergency  antiseptic  which  could 
be  used.  Every  first  aid  kit  of  the  enlisted  medical  personnel  of  the 
American  Army  contains  tincture  of  iodin. 

There  is  no  question  but  that  war  wounds  have  developed  extremely 
serious  infections  which  are  seldom  seen  in  industrial  surgery.  These 
soldiers  have  been  subjected  to  more  terrific  traumatisms,  have  had 
their  filthy  clothes  ground  into  the  flesh  and  in  a  great  many  cases 
have  not  reached  the  surgeon  until  several  hours  afterward,  often 
with  the  parts  badly  infected.  Some  heroic  method  of  treatment 
was  necessary  to  check  these  infections  and  to  overcome  the  excessive 
period  of  hospital  treatment  which  was  so  common  in  the  early  days 
of  the  war.  The  reports  of  Dr.  Carrel  and  other  enthusiastic  users 
of  the  Carrel-Dakin  solution  convinced  practically  the  entire  pro- 
fession that  the  continuous  use  of  this  antiseptic  in  these  infected 
areas  has  been  one  of  the  greatest  advances  made  in  war  surgery. 
Recent  American  reports  show  that,  as  the  hospitals  have  been  pushed 
nearer  the  front  and  the  transportation  of  the  wounded  to  the  surgeon 
has  been  expedited,  the  number  of  serious  infections  has  been  decreas- 
ing. It  is  conceivable  that  if  these  patients  could  be  treated  immedi- 
ately by  the  surgeons,  the  elaborate  Carrel-Dakin  method  would  be 
needed  only  in  the  exceptional  cases. 

In  accident  surgery  in  industry  the  injured  either  receive  this 
immediate  care  by  the  surgeon  or  medical  care  is  very  shortly  given. 
If,  combined  with  this,  tincture  of  iodin  is  applied  to  the  injured  part, 
no  matter  how  excessive  the  injury,  these  severe  infections  seldom 
occur  and  the  Carrel-Dakin  treatment  is  correspondingly  rarely  needed. 
These  wounds,  receiving  the  immediate  surgical  attention  and  the 
early  application  of  an  antiseptic,  have  been  successfully  closed  in  the 


EMERGENCY    SURGERY  517 

majority  of  cases  without  subsequent  infection  developing.  This 
treatment,  with  its  accompanying  careful  repair,  is  certainly  much 
wiser  than  to  insert  a  number  of  tubes  into  the  wound  and  start  the 
constant  irrigation  with  the  Carrel-Dakin  solution,  for,  as  stated 
above,  experience  has  proven  that  the  majority  of  such  cases  healed 
rapidly  and  with  primary  intention.  I  do  not  believe  that  Dr.  Carrel 
himself,  would  advocate  any  other  line  of  treatment.  However,  when 
any  of  these  wounds  show  signs  of  infection  or  when,  because  of 
neglected  early  care,  the  surgeon  is  confronted  with  a  seriously  in- 
fected case,  the  Carrel-Dakin  solution  may  very  wisely  be  employed. 

The  point  I  am  trying  to  make  is  that  the  judgment  of  the  surgeon 
in  industry  must  not  be  warped  by  the  new  methods  developed  for  the 
more  serious  war  injured.  On  the  other  hand,  war  surgery  has 
developed  many  new  measures  which  will  improve  the  technic  and 
efficiency  of  all  accident  surgery  and  the  surgeon  in  industry  must 
develop  a  keen  judgment  in  deciding  which  of  these  measures  is  an 
improvement  or  is  essential  and  which  of  them  is  unnecessary  when 
the  nature  of  the  case  and  the  quicker  methods  of  handling  it  are 
'Considered. 

In  this  connection  the  author  desires  to  publish  a  report  of  three 
cases  with  comments  on  each,  which  emphasizes  the  value  of  tincture 
of  iodin,  which  Dr.  Charles  A.  Lauffer  of  the  Westinghouse  Company 
gave  to  him  recently: 

"  1.  Charles  W.,  L6-42. 

''Injured  6/18/17,  resumed  work  10/15/17. 

"Mode  of  Accident. — While  standing  on  a  ladder  to  repair  a  line, 
reaching  to  the  right,  patient  threw  out  his  left  foot  to  balance  himself. 
This  foot  came  in  contact  with  a  36"  fan,  driven  at  high  speed, 
employed  for  ventilating,  located  near  the  roof  in  P-2. 

"Extent  of  Injury. — Patient  was  on  the  operating  table  at  Braddock 
General  Hospital  within  an  hour  of  the  injury.  He  was  reluctant 
about  giving  his  consent  for  the  amputation  of  the  first  and  second 
toes,  until  a  mirror  was  provided,  enabling  him  to  see  for  himself  the 
extent  of  the  damage  on  the  plantar  surface  of  the  foot,  and  the  com- 
minuted fractures  of  these  toes.  Not  only  were  all  the  tissues  ground 
from  the  plantar  surface  of  these  two  toes,  but  from  the  sole  of  the 
foot  two  inches  beyond  the  insertion  of  these  toes. 

"Surgical  Treatment. — Tincture  of  iodin  was  used  at  once.  Very 
tenacious  black  dirt  was  inground,  making  it  necessary  to  use  the 
scissors,  in  addition  to  gasoHne  and  tincture  of  iodin  in  abundance, 
in  cleansing  the  lacerated  tissues.  It  required  an  hour  to  clean  the 
wound,  and  another  half  hour  for  the  operative  procedure.  The  bones 
were  sacrificed  from  the  big  toe  and  the  second  toe,  and  the  dorsal  and 
lateral  skin  of  these  toes,  as  much  as  remained  of  it,  was  employed  to 


518  INDUSTRIAL    MEDICINE    AND    SURGERY 

cover  in  the  defect  on  the  sole  of  the  foot.  Tincture  of  iodin  was 
employed  to  excess  and  an  iodoform  drain  was  inserted  at  the  time  of 
operation. 

"Comment. — We  expected  to  employ  Dakin's  solution  subsequently, 
should  infection  set  in,  but  this  was  not  required.  A  staff  member, 
a  railroad  surgeon,  present  when  we  operated  the  case,  remarked: 
'  What  an  excellent  case  on  which  to  try  out  Dakin's  solution.  Put 
in  tubes,  do  no  washing  nor  cleaning,  just  bandage  it  up;  continue  the 
Dakin  solution  until  the  slough  has  separated.^ 

"  This  recommendation  was  abhorrent;  by  cleansing  and  closing  the 
wound,  we  avoided  the  implantation  of  infection,  and  within  24  hours, 
had  a  comfortable,  well  pleased  patient  on  the  high  road  to  recovery; 
results  justified  the  procedure  followed. 

"  X-Ray  No.  1025  exhibits  fractures  of  all  five  metatarsals,  and  the 
middle  phalanx  of  the  third  toe;  it  was  this  extreme  traumatism,  not 
suspected  at  the  time  we  operated  his  toes,  that  retarded  his  complete 
recovery. 

'2.  John  P.,  SK-323. 

Injured  7/17/17,  discharged  cured  8/7/17.  Patient  was  a  Greek, 
joined  the  army,  and  is  now  in  camp.     He  is  fully  recovered. 

' '  Mode  of  Accident. — Patient  loaded  sheet  iron  on  small  cars,  drawn 
by  motor  trucks.  The  sheets  in  this  instance  extended  out  beyond  the 
end  of  the  car  on  which  it  was  loaded.  The  motor  truck  slid  in  crossing 
slippery  dinkey  tracks,  and  the  end  car  was  switched  around,  the  sheet 
iron  striking  the  patient,  while  he  stood  in  a  narrow  doorway  where 
he  could  not  escape. 

"Extent  of  Injury. — The  external  ham  string  tendons  and  muscles 
were  completely  severed  in  two  places  about  an  inch  apart,  in  the 
popliteal  area  and  the  outer  aspect  of  the  thigh;  the  wound  was  very 
dirty,  so  was  the  patient's  skin.     The  large  vessels  were  not  cut. 

' '  Surgical  Treatment . — Tincture  of  iodin  was  applied  and  the  patient 
was  removed  at  once  from  the  Works  Dispensary  to  the  Westinghouse 
Ward  in  the  Braddock  General  Hospital,  Braddock,  Pa.  Vicinity  of 
the  wound  was  carefully  shaved,  and  cleaned  with  gasohne,  then 
tincture  of  iodin  was  lavishly  used  in  and  about  the  wound.  Severed 
tendons,  muscles,  and  fascia  were  approximated  with  catgut  sutures, 
which  also  controlled  the  bleeding.  The  fascia  lata  could  not  be  en- 
tirely approximated,  but  nature  evidently  filled  in  the  defect.  Iodo- 
form gauze  drain  was  inserted,  to  care  for  oozing,  and  leg  was  dressed 
in  fixation  dressings,  at  approximately  10°  flexion.  There  was  no 
infection  at  any  time,  and  the  patient  was  comfortable;  heahng  was 
nearly  as  rapid  as  in  a  surgical,  non-traumatic  wound. 

"Comment. — We  are  of  the  opinion  that  the  immediate  use  of 
tincture  of  iodin  gave  us  superior  results,  and  the  preliminary  use  of 


EMERGENCY    SURGERY  519 

Dakin's  solution   before   closing  the   wound   would   not   have   been 
justifiable. 

"3.  Alfred  Jackson,  K20-107. 

"Injured  9/20/17,  still  under  treatment. 

"Mode  of  Accident. — First  day  at  work,  had  been  onthe  job  just 
33-^  hours.  A  terminal  fell  behind  the  carriage  of  a  milling  machine. 
Without  stopping  the  machine,  he  reached  behind  the  carriage  for  the 
terminal;  the  carriage  drew  his  forearm  against  the  saw. 

Extent  of  Inj  ury . — The  saw  lacerated  the  soft  tissues  of  his  forearm, 
severing  all  the  muscles  and  other  structures,  exposing  both  bones  of 
the  forearm.     Severe  arterial  hemorrhage. 

"  Surgical  Treatment. — Tincture  of  iodin  applied.  Tourniquet 
applied  to  the  arm  did  not  adequately  control  the  squirting  arteries. 
Four  bleeding  points  were  sutured  in  the  works  dispensary.  Tincture 
of  iodin  was  freely  used,  and  he  was  sent  to  the  Westinghouse  Ward 
in  the  Braddock  General  Hospital,  Braddock,  Pa. 

"  Foreign  matter  was  removed  from  the  wound,  the  muscles  and 
fascia  were  approximated  with  catgut  sutures;  the  median  nerve  was 
also  sutured.  The  surgeon  was  too  busy  suturing  to  count  the  number 
of  muscles  that  had  to  be  united,  nor  did  he  count  the  number  of 
buried  sutures. 

"The  wound  has  healed  kindly,  there  has  been  no  pus.  He  has  a 
fair  functional  recovery  of  the  use  of  the  hand,  but  he  has  not  yet 
sufficiently  recovered  strength  in  the  hand  to  be  able  to  resume  work. 

"  Comment. — When  such  a  wound  can  be  treated  the  hour  of  the 
injury,  the  use  of  tincture  of  iodin  as  an  antiseptic  permits  of  closing 
the  wound.  Even  should  infection  arise,  which  is  always  a  possibiHty, 
— though  infection  is  a  rare  occurrence,  when  rubber  gloves  are  used  and 
antiseptics  are  freely  employed — the  wound  can  be  opened,  drained, 
and  Dakin's  solution  resorted  to,  to  control  the  infection." 

The  general  and  local  measures  employed  in  the  immediate  emer- 
gency care  of  the  patient  have  a  very  direct  bearing  on  the  prevention 
of  infections. 

Rest  is  one  of  the  most  essential  preventive  measures.  By  rest 
the  body  is  enabled  to  overcome  the  shock  and  general  injury  which 
it  has  received  when  an  accident  occurs  and  can  thus  more  rapidly 
recuperate  those  body  forces  necessary  to  combat  the  invading 
bacteria. 

Thus  the  gentlest  manipulation  of  the  injured  member  with  early 
immobilization  is  required  to  give  this  needed  rest.  In  the  severer 
injuries  rest  for  the  entire  body  should  be  afforded  as  soon  as  possible. 
Comfort,  warmth  and  nourishment  are  necessary  adjuncts  to  the 
rapid  recuperation  of  the  body  forces. 

When  it  is  necessary  to  remove  the  clothing  to  expose  the  injured 


520  INDUSTRIAL   MEDICINE    AND    SURGERY 

region  the  same  should  be  cut  away  rather  than  the  slower  and  more 
painful  method  of  undressing  the  patient. 

The  cleansing  of  the  wound  is  another  important  preventive 
measure.  No  injured  part  should  be  unnecessarily  handled  in  securing 
this  cleansing.  Neither  should  any  method  be  employed  which  would 
tend  to  grind  dirt  or  other  infected  material  deeper  into  the  wound. 
For  this  reason,  washing  the  wound  with  soap  and  water  or  with 
bichlorid  solution,  or  other  lotion  is  practically  obsolete.  The  author 
has  frequently  seen  nurses  and  surgical  assistants,  especially  the  latter 
when  they  are  lay  assistants,  and  even  the  enlisted  medical  personnel 
in  the  army  wash  open  wounds  with  water,  then  with  bichlorid,  then 
with  alcohol,  dabbing  at  them  and  otherwise  abusing  the  injured 
tissues  until  it  is  no  wond:r  that  in  ections  occur.  One  of  the  most 
essential  things  to  teach  these  assistants  is  to  leave  these  wounds  alone. 
Even  many  surgeons  have  yet  to  learn  this  lesson.  Bleeding  should 
not  be  checked  immediately  in  any  wound  as  this  usually  is  nature's 
method  of  washing  it  out.  After  painting  the  injury  with  tincture  of 
iodin  the  adjacent  skin  can  best  be  cleansed  with  gasoline,  benzin,  or 
alcohol.  If  the  dirty  skin  about  the  wound  is  thoroughly  painted  with 
iodin  even  this  cleansing  is  not  necessary.  However,  the  patients 
often  feel  that  their  injury  is  neglected  if  the  adjacent  surface  of  the 
body,  especially  that  portion  immediately  under  the  dressing,  is  not 
cleansed.  I  never  dress  a  fresh  wound  without  carefully  explaining 
to  the  patient  my  reasons  for  not  washing  it  with  soap  and  water, 
or  otherwise  insulting  the .  parts.  Taking  the  patient  into  your 
confidence  and  explaining  such  details  as  this  is  one  of  the  best  ways 
of  securing  his  co-operation  and  is  a  procedure  in  emergency  surgery 
which  is  too  often  neglected,  especially  by  the  young  surgeon,  fresh 
from  hospital  or  dispensary  training.  When  a  wound  occurs  in  the 
hairy  parts  of  the  body,  shaving  should  be  a  routine  cleansing  meas- 
ure. Before  shaving  the  hair  next  to  the  wound  it  should  be  painted 
with  iodin.  A  sharp  razor  should  be  used  so  that  dry  shaving  can 
be  done.  Always  shave  away  from  the  wound.  Any  loose  hair 
falling  into  the  wound  should  be  carefully  removed  with  sterile  forceps. 

All  foreign  material  which  has  entered  the  wound  should  be 
removed.  This  should  not  be  done  until  the  wound  has  been  treated 
with  tincture  of  iodin  and  then  should  be  accompanied  with  the  least 
possible  manipulation  of  the  injured  tissues.  The  probing  of  wounds 
with  the  finger  is  a  dangerous  practice  and  in  the  few  cases  where 
necessary  a  sterile  rubber  glove  should  always  be  worn.  When  the 
entering  wound  is  small  and  one  is  convinced  that  infected  material 
has  been  carried  into  deeper  tissues  the  opening  should  be  enlarged 
and  the  foreign  material  carefully  removed  by  sterile  forceps.  When 
small  pieces  of  steel  or  bullets  penetrate  the  body  these  should  be 


EMERGENCY    SURGERY  521 

carefully  located  by  rc-ray  before  an  effort  is  made  to  remove  them, 
unless  their  location  is  so  evident  that  the  operation  can  be  readily 
performed.  Many  such  small  pieces  of  foreign  material  enter  the 
body  and  never  cause  any  trouble  if  proper  sterihzation  of  the  tract  is 
accomplished.  In  fact,  meddlesome  interference  in  these  cases  is  often 
more  harmful  than  if  the  part  was  left  absolutely  alone.  Here  again 
the  keenest  surgical  judgment  is  necessary  and  is  only  developed  by 
experience.  In  accident  surgery  in  industry  the  foreign  materials 
usually  penetrating  the  tissues  are  splinters,  particles  of  clothing,  pieces 
of  steel  or  pieces  of  a  tool  which  broke  off  after  penetrating  the  body, 
such  as  a  needle — so  common  among  garment  makers.  The  removal 
of  these  materials  is  usually -essential  to  the  prevention  of  infections. 

All  loose  tags  of  skin  or  other  soft  tissues  so  damaged  that  they 
are  bound  to  become  necrotic  should  be  trimmed  away.  If  the  wound 
is  seen  after  several  hours  and  has  been  caused  by  an  object  which 
undoubtedly  will  cause  the  tissue  to  become  infected,  the  tract  of  the 
wound  may  be  thoroughly  dissected,  sterilized  and  closed  as  is  being 
practised  in  war  surgery  to-day.  As  a  general  rule,  however,  every 
effort  should  be  made  to  save  all  of  the  soft  parts  so  as  to 
better  facilitate  closing  and  healing.  When  loose  particles  of  bone 
which  have  been  deprived  of  periosteum  are  scattered  about  the 
wound  these  should  be  removed.  Bone  adherent  to  the  periosteum 
should  be  replaced. 

Drainage  is  a  very  essential  factor  in  the  prevention  of  infections 
and  when  to  and  when  not  to  insert  drainage  into  a  wound  requires 
most  careful  consideration  on  the  part  of  the  surgeon.  As  a  general 
rule,  incised  wounds  which  have  been  treated  with  iodin  or  similar 
reliable  antiseptic  can  be  closed  without  drainage.  Extensive  lacer- 
ated wounds  even  though  treated  immediately  with  an  antiseptic  can 
be  closed  but  only  after  drainage  is  established.  Severe  crushing 
wounds  or  deep  penetrating  wounds  after  sterilization  should  only  be 
partially  closed,  sufficient  opening  being  left  for  the  introduction  of 
good  drainage.  Wounds  already  showing  signs  of  infection  should 
never  be  completely  closed  and  thorough  drainage  is  usually  indicated. 
An  exception  to  this  may  be  in  the  case  of  small  incised  wounds,  mildly 
infected,  which  can  be  thoroughly  sterilized  and  then  closed  with  only 
small  drainage  provided. 

Many  kinds  of  drainage  material  are  used.  In  large  wounds  rubber 
tubing  or  a  section  of  tubing,  twisted  rubber  or  gutta  percha  are  best 
adapted  for  drainage.  In  many  cases,  especially  if  hemorrhage  is 
profuse,  gauze  is  required  but  as  a  rule  gauze  drainage  tends  to  act  as 
a  pack  and  defeats  its  own  purpose.  Plain  sterile  gauze  is  now  used 
for  drainage  just  as  often  as  iodoform  gauze,  formalin  gauze  or  other 
such  chemically  treated  material.     In  smaller  wounds  a  small  rubber 


522  INDUSTRIAL    MEDICINE    AND    SURGERY 

band,  or  two  or  three  strands  of  silk  gut  twisted  together,  affords 
excellent  drainage. 

The  question  of  closing  the  wound  often  plays  an  important  part 
in  infection  prevention.  Many  wounds  which  were  formerly  left  open 
are  now  treated  with  iodin  and  then  carefully  closed  without  ever 
becoming  infected,  whereas  if  left  open  healing  is  delayed  and  the 
dangers  of  subsequent  infection  increased.  Careless  coaptation  of 
the  tissues,  leaving  dead  spaces  in  the  tissues  below  the  skin  have 
frequently  resulted  in  infections.  Over-zealousness  in  coaptation 
may  shut  off  the  blood  supply  and  cause  necrosis  of  the  edge  of  the 
wound  followed  by  infection.  Frequently  one  sees  a  good  surgeon, 
who  otherwise  has  the  most  perfect  technic  in  the  operating  room, 
suturing  one  of  these  emergency  cases  without  observing  any  of  the 
finer  points  in  asepsis.  A  wound  which  is  to  be  closed  by  sutures  in 
the  office  or  the  dispensary  should  be  carefully  sterilized,  surrounded 
by  sterile  gauze  or  a  small  sheet,  resembling  a  miniature  laparotomy 
sheet,  and  treated  only  after  the  hands  and  instruments  have  likewise . 
been  sterilized.  Sterile  suturing  material  should  be  used  and  should 
not  be  allowed  to  drag  across  unclean  portions  of  the  patient's  body 
while  being  inserted. 

Tetanus  (Lockjaw). — This  infection,  due  to  the  Bacillus  tetani 
is  one  of  the  most  feared  complications  following  injuries.  In  order  to 
prevent  this  infection  some  surgeons  have  advised  the  injection  of  an 
immunizing  dose  of  tetanus  antitoxin  in  all  punctured  or  lacerated 
wounds.  Ten  years  ago  this  prophylactic  measure  was  used  quite 
extensively  in  industry.  However,  with  the  increased  use  of  antiseptics 
and  the  more  immediate  treatment  of  wounds  by  the  surgeon  antitoxin 
has  become  less  necessary.  In  the  first  year  of  the  war  many  soldiers 
died  of  lockjaw.  To  combat^this,  antitoxin  was  administered  at  the 
first  aid  station  farthest  front.  The  wonderful  results  obtained 
by  the  use  of  this  prophylaxis  proved  the  great  value  of  antitoxin. 
These  wounds  were  practically  all  soil  infected. 

In  industry  it  is  only  the  occasional  wound  which  is  soil  infected. 
The  patient  whose  foot  is  crushed  by  an  automobile  or  a  truck  on  the 
street  is  a  logical  case  for  antitoxin  but  the  foot  crushed  by  machinery 
or  falling  timber  in  the  plant  or  even  by  the  locomotive  on  the  raih-oad 
track  where  the  dirt  consists  chiefly  of  cinders,  is  very  seldom  in  danger 
of  developing  lockjaw  providing  thorough  steriHzation  with  iodin 
can  take  place  within  the  first  hour.  We  must  not  think  it 
necessary  to  give  every  industrial  wound  an  immunizing  dose  of 
tetanus  antitoxin  when  we  once  more  return  to  our  private  work. 
Here  again  the  judgment  of  the  surgeon  must  not  be  warped  by  our 
experience  in  war  surgery.     Nevertheless  we  will  all  be  more  faithful 


EMERGENCY    SURGERY  523 

in  administering  it  in  the  suspicious  cases  where  soil  infection  makes' 
lockjaw  imminent. 

In  the  author's  experience,  antitetanic  serum  as  a  prophylaxis 
was  only  administered  routinely  during  the  first  year  of  his  emergency 
surgery.  No  cases  of  lockjaw  developed  during  that  year  and  neither 
have  any  cases  developed  among  the  employees  under  his  care  during 
the  succeeding  nine  years.  His  predecessor  in  the  same  industry 
used  tetanus  antitoxin  on  every  puncture  wound  due  to  nails  and  on 
all  severe  lacerated  wounds.  The  records  show  that  three  cases  of 
tetanus  developed  during  the  period  he  was  in  charge.  I  am  convinced 
that  in  this  industrial  work  the  thorough  sterihzation  of  the  wound 
by  tincture  of  iodin  makes  the  need  of  the  immunizing  dose  of  anti- 
toxin practically  unnecessary,  thereby  limiting  its  use  to  the  occasional 
soil  infected  case. 

When  the  immunizing  dose  is  given  it  consists  of  from  500  to  1000 
c.c.  of  antitoxin  injected  subcutaneously  above  the  wound.  Some 
insist  on  injecting  it  directly  into  the  nearest  nerve  trunk. 

Hemorrhages. — Hemorrhage  is  another  complication,  especially 
in  extensive  wounds,  which  it  is  always  necessary  to  prevent.  This 
is  accomplished  by  firmly  packing  the  wound  or  by  applying  a  thick 
sterile  gauze  dressing  and  firmly  binding  in  place  or  by  clamping  the 
bleeding  vessels  with  clamps  left  on  for  several  hours,  or  by  the  direct 
apphcation  of  ligatures  to  the  bleeding  points.  When  ligatures  are 
necessary  in  the  emergency  treatment  of  these  extensive  wounds 
it  is  well  to  leave  their  ends  long  in  order  to  easily  locate  the  bleeding 
vessels  in  case  of  subsequent  hemorrhage.  At  times  it  may  be  neces- 
sary to  use  a  tourniquet  for  two  or  three  hours  in  order  to  control  and 
prevent  subsequent  hemorrhage.  Such  a  continued  use  of  the  tour- 
niquet should  always  be  under  the  direct  supervision  of  the  surgeon 
and  great  care  should  be  exercised  to  prevent  subsequent  gangrene. 

Deformity.— Deformity  naturally  is  more  often  due  to  the  severity 
of  the  wound  and  to  that  extent  is  beyond  the  control  of  the  surgeon. 
But  in  every  case  the  physician  must  begin  thinking  of  the  prevention 
of  undue  deformities  at  the  time  he  administers  the  emergency  treat- 
ment and  must  continue  to  constantly  think  along  these  lines 
during  the  subsequent  treatments.  Many  a  case  of  deformity  can 
be  prevented  by  immediately  restoring  the  limb  to  its  proper  position 
whereas  if  this  is  left  for 'some  future  treatment  permanent  damage 
may  have  occurred.  In  preventing  infections  one  is  likewise  pre- 
venting the  dangers  of  deformity. 

COMBAT  IMMEDIATE  COMPLICATIONS 

Impending  Death. — In  emergency  surgery  the  physician  faces  some 
of  his  greatest  battles  against  impending  death  and  many  a  case  is 


524  INDUSTRIAL    MEDICINE    AND    SURGERY 

saved  by  the  experienced  surgeon  who  does  nothing  with  the  wound 
in  such  a  crisis  but  devotes  his  entire  attention  to  assisting  the  patient 
to  overcome  the  terrific  shock  which  is  threatening  his  hfe.  On  the 
other  hand  many  a  case  is  lost  in  this  critical  moment  by  manipulating 
the  injured  part  or  attempting  surgical  procedures  before  this  shock  is 
overcome.  This  can  best  be  illustrated  by  two  cases  which  the  author 
observed  in  two  different  hospitals  during  the  same  day: 

Case  One:  A  man  was  carried  into  the  hospital  after  being  run 
over  by  a  street  car.  His  left  thigh  was  crushed  to  the  hip-joint 
and  was  held  in  place  only  by  the  gluteal  muscles.  There  was  a  warm 
bed  in  the  receiving  ward  held  in  readiness  for  such  shock  cases. 
After  cutting  the  trouser  leg  away  from  this  wound  the  surgeon 
simply  clamped  the  femoral  vessel  which  was  exposed  but  not  bleeding 
and  then  covered  the  wound  with  a  large  sterile  pad  and  immediately 
placed  the  man,  with  his  clothes  on,  in  the  warm  bed.  No  further 
attention  was  paid  to  the  injured  part,  but  by  means  of  salt  solution 
intravenously,  hot  coffee  per  rectum  and  stimulants  the  shock  was 
combated  for  the  next  ten  hours.  The  wound  was  watched  carefully 
for  possible  hemorrhage  following  the  use  of  the  stimulants  and 
salt  solution  but  only  once  was  it  necessary  to  apply  an  additional 
artery  forceps.  After  the  immediate  danger  of  death  was  over- 
come the  wound  was  sterilized  by  pouring  iodin  over  it  but  no  other 
effort  was  made  toward  repair  until  all  signs  of  shock  were  over- 
come. Twelve  hours  later  the  patient  was  subjected  to  a  hasty 
amputation  at  the  hip-joint  under  ether  anesthesia  but  no  time 
was  consumed  in  endeavoring  to  carefully  coapt  the  various  layers 
of  tissue.  This  was  left  for  a  subsequent  operation  when  the  patient's 
condition  warranted  it.  This  man  made  an  excellent  recovery 
without  infection. 

Case  Two:  That  night  the  author  was  called  to  another  hospital 
to  see  a  man  who  had  been  run  over  by  a  nearby  street  car  and  who  was 
immediately  carried  to  the  hospital.  This  patient  had  likewise 
suffered  a  severe  crushing  wound  at  the  hip-joint  and  in  many  respects 
was  almost  identical  with  the  other  case.  The  patient  had  been 
immediately  carried  to  the  operating  room  and  the  physician  who  was 
called  in  to  give  emergency  care  had  started  combating  the  shock 
but  at  the  same  time  had  proceeded  to  give  surgical  attention  to  the 
wound.  The  patient's  body  and  right  limb  were  covered  with  blankets 
and  hot  water  bottles  were  in  place.  Normal  salt  solution  was  being 
administered  intravenously,  stimulants  had  been  given.  While  the 
patient  was  being  anesthetized  with  ether,  the  physician  had  pro- 
ceeded to  cut  away  the  mangled  limb  and  was  carefully  coapting  the 
various  tissues.  I  arrived  at  this  stage  and  recommended  the  imme- 
diate application  of  a  large  sterile  pad  to  the  stump,  leaving  subsequent 


EMERGENCY    SURGERY  525 

repair  to  some  future  date  if  the  patient  recovered.  This  was  doubtful 
considering  his  condition  at  that  moment.  Before  this  recommenda- 
tion could  be  acted  upon  the  patient  died. 

Too  much  emphasis  cannot  be  placed  upon  the  importance  of 
combating  these  severe  shock  conditions  before  attempting  any- 
radical  emergency  treatment  of  the  wound  itself.  The  surgeon  must 
have  the  patience  of  an  obstetrician  in  such  cases  and  stick  by  the 
patient;  biding  the  time  till  it  is  safe  to  proceed  with  the  repair 
work. 

Shock  and  Hemorrhage. — Shock  and  hemorrhage,  either  singly 
or  combined,  play  an  important  part  in  the  complications  which  an 
emergency  surgeon  must  combat  immediately  following  an  accident. 
There  are  all  grades  of  both  shock  and  hemorrhage  and  both  may  occur 
immediately  (primary)  or  late  (secondary  or  delayed).  Both  may 
gradually  lead  to  a  condition  spoken  of  as  "collapse"  and  death 
may  follow  this  state. 

Previous  to  the  war  these  conditions  were  most  thoroughly  de- 
scribed by  Crile  and  his  methods  of  treating  them  have  played  an  im- 
portant part  in  the  treatment  of  our  soldiers  affected  by  these  con- 
ditions. During  this  period  of  war  surgery,  research  in  the  field  of 
shock  and  hemorrhage  have  added  considerably  to  our  knowledge 
of  these  subjects  and  the  emergency  surgeon  in  industry  should  famil- 
iarize himself  with  these  various  reports  from  the  war  zone  in  France. 

One  of  the  interesting  contributions  of  the  physiologic  changes 
which  take  place  in  the  body  during  traumatic  shock  has  appeared 
recently  in  the  report  from  the  Central  Medical  Department  Labora- 
tory of  the  American  Expeditionary  Forces  in  France,  under  the  title 
of  "The  critical  level  of  a  falling  blood-pressure  and  the  modifications 
of  hemorrhage. " 

"Clinical  and  experimental  observations  have  shown  that  death 
after  severe  hemorrhage  is  not  immediate,  but  may  occur  after  the 
la.pse  of  some  hours.  This  fact  is  explained  by  the  gradual  damage  of 
essential  organs  by  partial  anemia  until  they  fail  to  perform  their 
functions.  If  hemorrhage  is  repeated,  non-volatile  acid  (lactic) 
will  appear  in  the  blood.  Other  conditions  which  markedly  lessen 
the  oxygen  supply  to  the  tissues  (CO  poisoning,  rebreathing  expired 
air),  have  the  same  effect.  Lactic  acid  thus  produced  unites  with 
the  sodium  of  the  sodium  bicarbonate  in  the  blood,  drives  off  CO2, 
and  thereby  produces  a  reduction  of  the  "alkali  reserve"  (indicated 
by  a  diminished  capacity  of  the  plasma  to  take  up  CO2).  When  the 
CO2  capacity  is  reduced  to  less  than  50  volumes  per  cent.,  under 
standard  conditions,  "acidosis"  is  said  to  be  present.  Reduction 
of  the  alkali  reserve  in  such  circumstances,  may  be  taken  as  an  in- 
dication of  insufficient  oxygen  supply  to  the  tissues. 


526 


INDUSTRIAL    MEDICINE    AND    SURGERY 


"As  arterial  blood-pressure  falls,  the  rate  of  circulation  of  the  blood 
decreases.  Then,  though  the  red  blood  corpuscles  leave  the  lungs 
normally  laden  with  oxygen,  they  may  not  carry  a  normal  supply 
to  the  tissues  because  they  move  too  slowly.  In  that  case  the  condition 
would  be  similar  to  other  conditions  in  which  oxygen  want  exists; 
non-volatile  acid  would  result,  and  the  alkali  reserve  be  lessened. 

"In  traumatic  shock  the  blood-pressure  is  low  and  the  circulation 
is  therefore  sluggish.  For  therapeutic  purposes,  it  is  important 
to  know  at  what  point  in  a  falling  blood-pressure,  the  oxygen  supply 
begins  to  be  insufficient,  as  indicated  by  a  lessening  of  the  alkali  reserve. 

"Experiments  in  the  Laboratory  of  Surgical  Research  at  the  Central 
Medical  Department  Laboratory  have  shown  that  if  arterial  pressure  is 
lowered  to  80  mm.  of  mercury  for  an  hour,  the  alkali  reserve  is  not 
reduced;  but  if  lowered  to  70  mm.,  the  reserve  begins  to  fall;  and  if 
lowered  to  60  mm.,  it  falls  still  faster  {i.e.,  the  oxygen  supply  is  less 
adequate,  and  the  production  of  non-volatile  acid  is  more  rapid).  A 
critical  level  of  oxygen  supply  to  the  tissues  is  reached,  therefore,  when 
the  arterial  pressure  is  experimentally  lowered  to  less  than  80  mm.  of 
mercury.  Average  figures  from  43  cases  of  shock  and  hemorrhage 
studied  last  summer  at  Bethune  reveal  in  human  beings  similar 
relations : 


Systolic  blobd-pressure,   . 
mm.  mercury 

Average  CO2  capacity, 
vols,  per  cent. 

No.  of  cases 

90-100 

49 

12 

* 

80-  90 

49 

5 

70-  80 

43 

10 

60-  70 

36 

11 

50-  60 

24 

5 

"As  these  figures  clearly  show,  a  reduction  of  the  alkali  reserve 
below  50  volumes  per  cent.  CO2  capacity,  or  a  condition  of  "acidosis," 
occurred  when  the  systolic  pressure  was  lower  than  80  mm.  of  mercury; 
and  the  reduction  of  the  reserve  was  progressive  as  the  pressure  was 
progressively  lower.  It  appears,  therefore,  that  the  critical  level 
for  proper  oxygen  supply  to  the  tissues  is  approximately  80  mm. 
of  mercury,  systohc  arterial  pressure.  The  lower  the  pressure  below 
that  level,  the  less  is  the  circulation  able  to  meet  the  needs  of  the  tissues. 

"Experiments  show,  as  might  be  expected,  that  if  hemorrhage 
complicates  a  low  blood-pressure,  the  critical  level  is  higher  than  if 
no  loss  of  blood  has  occurred.  Thus,  if  20  per  cent,  of  the  blood  has 
been  lost,  the  pressure  cannot  be  lowered  to  80  mm.  without  indica- 
tions of  insufficient,  oxygen  supply  to  the  tissues. 

"In  the  treatment  of  shock  and  hemorrhage,  the  persistence  of 


EMERGENCY    SURGERY  527 

arterial  pressure  below  90  mm.  of  mercury  for  more  than  a  half  hour, 
without  sign  of  improvement,  though  the  patient  has  been  warmed 
and  rested,  should  call  for  treatment  by  transfusion  of  blood  or  the 
infusion  of  acacia  solution.  If  the  pressure  is  much  below  90  mm., 
e.g.,  50  or  60  mm.,  such  treatment  should  be  instituted  immediately." 

The  symptoms  of  shock  are  most  graphically  described  by  John 
J.  Moorhead  as  follows: 

"A  typical  case  presents  rather  a  characteristic  appearance  in  that 
the  patient  immediately  after  the  accident  is  unconscious  or  nearly 
so;  the  surface  of  the  body  is  pale,  cold  and  sweaty;  the  expression  is 
anxious;  the  eyes  are  shut  or  widely  open;  the  pupils  are  dull,  usually 
dilated,  and  slowly  responsive;  respiration  is  shallow  and  feeble  and 
often  intermittently  sighing;  the  pulse  is  weak,  compressible  and  ir- 
regular, and  often  slow  and  inactive;  if  very  arousable,  mental  tor- 
pidity is  the  rule;  sometimes  the  sphincters  are  relaxed  and  nausea 
and  vomiting  may  occur;  the  temperature  is  subnormal  or  sHghtly 
elevated  at  first.  After  some  minutes,  or  later,  these  patients  grad- 
ually become  aroused,  the  color  returns,  the  mind  clears,  the  pulse 
and  respiration  strengthen,  and  they  recover." 

Other  much  more  severe  grades  may  remain  in  a  state  of  mental 
and  physical  depression  or  mental  torpor  for  many  hours  and  even 
die  in  deepening  coma  from  shock  alone,  although  death  from  this 
source  independently  is  quite  rare  and  should  not  be  accepted  as  a 
sole  cause  in  the  absence  of  an  autopsy. 

In  some  instances  a  condition  of  apathy  is  replaced  by  one  of  ir- 
regular activity  of  a  somewhat  dehrious  type,  this  occurring  especially 
with  head  injuries  and  with  alcoholics;  this  is  a  so-called  erethistic  as 
distinguished  from  the  apathetic  or  ordinary  form,  and  it  is  very  closely 
allied  to  traumatic  delirium. 

Secondary  or  delayed  shock  may  appear  from  several  hours  to  two 
or  three  days  after  an  accident.  It  is  most  frequently  due  to  hemor- 
rhage or  may  appear  after  an  anesthetic  operative  procedure  has  been 
undertaken. 

Hemorrhage  gives  almost  the  same  symptoms  of  shock  especially 
as  the  two  so  often  occur  together.  A  patient  without  much  shock, 
however,  who  is  hemorrhaging,  will  gradually  develop  these  symptoms. 
Increasing  pallor  is  noticed;  the  pulse  becomes  soft  and  compressible, 
at  first  rapid  but  gradually  becoming  slower  and  irregular;  the  patient 
yawns  frequently  and  complains  of  thirst;  the  blood-pressure  be- 
comes lower  and  lower.  Unless  the  condition  is  checked  a  state  of 
collapse  gradually  develops,  followed  by  coma  and  death. 

Secondary  or  delayed  hemorrhages  frequently  occur  in  accident 
surgery  and  in  severe  injuries  the  surgeon  should  constantly  be  on 
the  lookout  for  the  above  symptoms. 


528  INDUSTRIAL    MEDICINE    AND    SURGERY 

When  shock  and  hemorrhage  are  coincidental  as  is  so  often  the  case 
in  those  accidents  diagnosed  as  internal  injuries,  it  is  often  very  diffi-. 
cult  to  differentiate  between  the  two.  It  is  very  important  to  make 
this  differentiation,  however,  as  the  treatment  must  frequently  be 
modified  where  the  two  exist  together.  For  instance,  when  shock 
alone  is  present;  the  repair  work  may  be  postponed  until  the  patient's 
condition  is  improved,  but  if  shock  and  hemorrhage  are  both  present 
or  if  the  shock  is  solely  due  to  hemorrhage,  the  finding  and  checking 
of  the  source  of  bleeding  is  the  paramount  consideration.  Often 
the  stimulation  and  especially  the  transfusions  which  are  administered 
in  case  of  shock  may  increase  or  even  create  a  hemorrhage.  Therefore, 
in  combating  shock,  one  must  constantly  be  on  the  lookout  for  hemor- 
rhage and  ready  to  immediately  check  the  same.  As  Moorhead  so 
aptly  states,  "shock  patients  get  better,  while  bleeding  patients  often 
get  worse  during  treatment  and  lapse  of  time." 

The  treatment  of  these  conditions  is  similar  after  the  hemorrhage 
is  controlled. .  In  fact  the  treatment  of  both  must  often  be  instituted 
while  endeavoring  to  check  the  hemorrhage. 

The  ordinary  shock  patient  will  recover  from  this  state  very  shortly 
by  the  simple  methods  of  rest;  keep  thoroughly  warm;  no  manipulation 
of  the  injured  part  or  if  necessary,  the  very  gentlest;  lowering  the 
head,  and  stimulation.  The  severe  cases  demand  all  of  the  above 
and  in  addition,  transfusion  or  infusion  of  normal  salt  solution  with 
or  without  adrenalin,  the  infusion  of  acacia  solution,  or  the  transfusion 
of  blood.  The  delay  in  administering  the  more  heroic  methods  has 
caused  a  fatal  termination  of  many  a  case  which  otherwise  might 
have  been  saved.  As  one  observer  in  the  war  zone  has  said,  ''Necessity 
for  transfusion  or  infusion  in  cases  of  shock  with  or  not  the  further 
cause  of  low  pressure  resulting  from  hemorrhage  can  be  detected 
earlier  and  with  greater  certainty  by  a  series  of  blood-pressure  obser- 
vations than  by  other  means.  A  warmed,  rested  patient  showing  a 
persistent  arterial  pressure  below  90  mm.  of  mercury  needs  help  at 
once  and  the  help  he  needs  is  infusion  or  transfusion." 

In  industrial  surgery  the  majority  of  these  shock  and  hemorrhage 
cases  will  or  should  receive  their  emergency  treatment  in  the  plant 
dispensary.  They  are  the  type  of  cases  which  formerly  so  frequently 
died  in  the  ambulance  on  the  way  to  the  hospital.  The  bringing  of 
the  surgeon  to  the  front  line  trench  in  industry  has  prevented  many 
such  deaths.  The  time  is  coming  when  a  very  hazardous  industry 
must  provide  this  immediate  treatment. 

Every  plant  surgeon  should  be  thoroughly  drilled  in  the  follow- 
ing treatment  of  a  patient  brought  to  the  dispensary  on  account  of 
severe  injuries: 

1.  Immediately  place  on  a  bed  or  on  the  dressing  table  and  cover 


EMERGENCY    SURGERY  529 

all  parts  of  the  body  except  the  injured  portion  with  warm  blankets, 
and  surround  the  body  with  hot  water  bottles.  Elevate  the  foot 
of  the  bed.  (My  surgical  nurse  carries  out  this  procedure  in  all  cases 
of  injury  whether  shock  symptoms  are  present  or  not,  automatically 
attending  to  the  comfort  of  the  patient  without  any  directions  from 
the  surgeon.) 

2.  If  shock  symptoms  are  present,  administer  at  once  a  hypo- 
dermic of  morphin.  If  the  condition  of  shock  is  mild,  this  may  be 
replaced  by  aromatic  spirits  of  ammonia. 

3.  While  this  treatment  is  being  carried  out,  carefully  inspect 
the  injured  part,  clamp  all  bleeding  points,  sterilize  with  iodin  and 
cover  with  a  sterile  pad.  Don't  take  time  to  carefully  bandage. 
Direct  the  rest  of  your  attention  to  combating  the  shock,  meanwhile 
watching  the  wound  carefully  for  a  recurring  hemorrhage. 

4.  If  the  condition  of  the  pulse  or  the  lowered  blood-pressure 
(the  nurse  or  an  assistant  has  already  taken  the  blood-pressure  and 
continues  to  do  so  at  frequent  intervals)  show  the  need  of  cardiac 
stimulation,  strychnia  one-thirtieth  of  a  grain  may  be  given,  or  better, 
adrenalin  or  camphor. 

The  author  keeps  two  things  constantly  ready  for  shock  cases, 
namely,  a  sterile  glass  irrigation  jar  containing  sterile  tubes  with 
sterile  needles  attached  for  the  infusion  or  transfusion  of  normal  salt 
solution;  and  a  fountain  syringe  with  a  large  size  catheter  attached 
for  the  administration  of  hot  normal  salt,  six  ounces,  and  whiskey, 
two  ounces,  per  rectum.  While  the  above  procedures  are  being  carried 
out,  the  surgical  nurse  and  her  assistant  sets  up  this  apparatus  and 
fills  the  first  with  the  sterile  normal  salt  solution  and  the  latter  with 
the  normal  salt  and  whiskey  solution.  They  do  this  even  though 
later  their  use  may  be  found  unnecessary. 

5.  If  the  shock  is  severe  and  the  blood-pressure  indicates  its  need, 
an  infusion  or  transfusion  of  normal  salt  solution  should  immediately 
be  given,  at  the  same  time  starting  the  rectal  stimulation.  The  body 
must  not  be  unduly  exposed  but  must  be  kept  warm  during  this  entire 
treatment. 

6.  Do  not  move  the  patient  from  the  dispensary  to  the  general 
hospital  until  this  condition  of  shock  has  been  overcome.  As  a  rule, 
after  three  or  four  hours,  even  these  extreme  cases  can  be  moved  to 
the  hospital.  Gentleness  and  great  care  must  attend  this  transpor- 
tation and  the  surgeon  should  stay  constantly  by  his  patient,  even 
riding  in  the  ambulance  with  him. 

Unless  the  danger  of  delaying  an  operation  is  of  greater  menace 
to  the  patient's  life  than  the  shock  condition,  all  operative  procedures 
should  be  postponed  until  the  latter  is  overcome.  The  need  for  an 
immediate  operation  may  cause  the  patient  to  be  rushed  to  the  hos- 

34 


530  INDUSTRIAL    MEDICINE    AND    SURGERY 

pital  at  once.  Contrary  to  the  opinions  of  many,  such  a  case  usually 
stands  the  effect  of  an  anesthetic  very  well,  the  patient's  condition 
seeming  to  improve  after  the  anesthetic  has  started.  Frequently 
the  symptoms  of  shock  return  and  the  condition  becomes  critical 
during  the  operative  procedure.  Crile's  method  of  blocking  the  nerves 
above  the  site"  of  the  injury  by  injection  will  often  prevent  this  re- 
currence of  shock  during  an  operation. 

Blood  transfusion  has  usually  been  considered  an  operative  pro- 
cedure suitable  only  for  the  hospital.  Recent  experience  has  proven 
that  quick  methods  of  blood  transfusion  by  the  use  of  a  large  hypo- 
dermic syringe  containing  2  per  cent,  solution  of  sodium  citrate,  so 
that  when  the  syringe  is  filled  there  will  be  one  part  citrate  to  ten 
parts  of  the  donor's  blood,  can  be  administered  with  good  effect  to 
these  hemorrhage  and  shock  patients.  Undoubtedly,  one  of  the  ad- 
vances in  surgery  as  a  result  of  the  war  will  be  a  commoner  use  of  blood 
transfusion. 

Resuscitation. — The  method  of  artificial  respiration  for  com- 
bating certain  types  of  shock,  suffocation,  asphyxiation  and  similar 
conditions  has  been  fully  described  in  the  chapter  on  First  Aid.  In 
addition  to  this,  many  industrial  dispensaries,  especially  in  those  in- 
dustries where  electrical  shock,  gas  poisoning  or  asphyxiation  are  liable 
to  occur,  have  included  pulmotors  as  a  part  of  their  equipment. 
Many  surgeons  claim  excellent  results  from  the  use  of  these  pulmotors. 
Universal  approval  of  the  various  devices  for  automatically  forcing 
respiration  has  not  been  given,  some  authorities  claiming  that  this 
procedure  is  dangerous.  There  is  no  question,  however,  but  that  this 
method  has  been  very  successful  in  many  cases  of  gas  asphyxiations. 

Circulatory  artificial  stimulation  is  another  means  of  resuscitation 
which  should  be  employed.  Rhythmic  pressure  over  the  heart  area, 
the  tongue  being  drawn  out,  combines  circulatory  with  respiratory 
stimulation,  according  to  Crile.  Some  have  advocated  the  digital 
rhythmic  compression  of  the  heart  itself  but  the  success  of  this  method 
is  very  doubtful. 

Freezing  or  Frost-bites. — Third  degree  frost-bites,  that  is,  those 
with  deep  ulcerations,  destruction  of  tissue  and  even  gangrene,  are 
not  usually  seen  in  industrial  practice.  Frost-bites  of  the  first  degree 
producing  redness  and  swelling  of  the  skin  are  not  uncommon  and  some 
even  show  the  blebs  or  blisters  of  the  second  degree  frost-bites.  The 
combating  of  immediate  complications  in  frost-bites  aims  at  the  res- 
toration of  circulation.  Such  patients  should  not  be  taken  into  a  warm 
temperature  at  once  but  gradually.  Friction  and  cold  applications 
afford  the  greatest  relief.  Cracked  ice  applied  direct  to  the  frost- 
bitten member  and  rubbed  back  and  forth  with  increasing  vigor  is  the 
best  method. 


EMERGENCY    SURGERY  531 

The  patient  that  has  suffered  an  extreme  case  of  freezing  should 
be  placed  in  a  cold  bath  in  a  cold  room  and  friction  applied  by  cold 
towels.  Gradually  the  temperature  of  the  bath  and  the  room  is  in- 
creased until  the  appearance  of  the  body  indicates  that  circulation 
has  been  re-established. 

Heat  Exhaustion. — Heat  exhaustion  is  not  uncommon  among 
employees  during  the  summer  months  when  they  must  work  in  hot 
places.  Heat  exhaustion  is  really  a  collapse  from  the  effects  of 
neat. 

Such  a  patient  develops  an  extreme  pallor;  the  skin  is  covered 
with  a  clammy  perspiration;  his  pulse  is  weak  and  rapid,  and  respira- 
tion is  rapid  and  shallow;  the  patient  is  never  unconscious  but  may 
be  in  a  state  of  collapse;  the  temperature  is  rarely  over  103°F.  and 
may  be  subnormal. 

The  patient  should  be  immediately  removed  to  a  cool  room,  should 
lie  down  with  the  head  lowered,  the  body  should  be  covered  with  a 
blanket  and  aromatic  spirits  of  ammonia  administered.  In  extreme 
cases,  rectal  stimulation  with  normal  salt  and  whiskey  and  hot  coffee, 
is  beneficial.  Such  patients  usually  require  rest,  comfort  and  mild 
stimulation  to  early  overcome  this  condition. 

Sunstroke. — This  condition  is  usually  caused  by  prolonged  ex- 
posure to  the  direct  rays  of  the  sun  or  it  may  be  due  to  excessive 
heat  indoors.  The  symptoms  develop  suddenly.  The  face  is  flushed 
and  the  skin  of  the  body  is  hot  and  dry.  The  temperature  of  the  body 
is  greatly  increased,  ranging  from  103°F.  to  as  high  as  109°F.,  even 
more  in  fatal  cases.  The  pulse  is  rapid  and  bounding,  later  followed 
by  a  weak,  irregular  pulse.  At  first  the  respiration  is  stertorous, 
later  becoming  rapid  and  shallow. 

The  treatment  in  this  condition  consists  in  reducing  the  temperature 
of  the  body  as  quickly  as  possible.  It  is  done  by  ice  water  sponging 
or  by  placing  the  patient  in  a  cold  bath  the  temperature  of  which  is 
gradually  decreased  by  the  application  of  ice.  This  is  kept  up  until 
the  body  temperature  is  lowered  and  consciousness  returns.  On 
the  first  indication  of  the  return  of  high  temperature  this  treatment 
should  be  repeated.  After  the  patient  is  placed  in  bed  ice  bags  should 
be  placed  on  his  head.  A  very  sudden  drop  in  temperature  usually 
indicates  a  fatal  termination.  At  the  same  time  the  collapse  must 
be  treated  by  cardiac  stimulation,  strychnia  and  caffein  being  most 
commonly  employed,  and  by  the  use  of  salt  solution  and  whiskey 
per  rectum. 

Every  industrial  dispensary  should  be  equipped  for  the  emergency 
treatment  of  both  heat  exhaustion  and  sunstroke.  After  a  fatal 
case  of  sunstroke,  the  author  had  a  bath  tub  installed  in  both  the 
men's  and  women's  toilets  in  connection  with  the  doctor's  office. 


532  INDUSTRIAL    MEDICINE    AND    SURGERY 

These  have  only  been  needed  in  two  cases  of  sunstroke  since  their  in- 
stallation but  both  cases  were  saved. 

The  combating  of  the  immediate  complications  in  the  three  last 
named  conditions  makes  up  a  definite  part  of  the  emergency  surgeon's 
work  in  industrial  practice. 

•  TEMPORARY  AND  PERMANENT  RELIEF 

The  majority  of  emergency  surgery  in  industry  consists  of  the  im- 
mediate permanent  treatment  of  wounds,  the  patient  returning  to 
work,  and  reporting  to  the  doctor's  office  for  his  subsequent  treat- 
ment. In  some  cases  the  permanent  relief  will  be  given  at  the  dis- 
pensary and  the  patient  is  then  sent  to  his  home  or  to  a  hospital  for 
the  subsequent  treatment. 

Many  employees  receiving  fractures,  severe  lacerations,  crushing 
wounds  and  loss  of  members  will  be  given  temporary  relief  at  the 
dispensary  and  then  sent  to  a  hospital  where  the  permanent  repair 
is  given  in  surroundings  better  adapted  to  major  work. 

Emergency  surgery  administered  for  either  the  temporary  or 
permanent  relief  usually  involve  the  following  methods: 

Closure  of  Wounds. — Consideration  was  given  to  this  procedure 
under  the  subhead  of  preventing  infections.  As  a  rule,  the  incised 
wounds  and  the  majority  of  lacerated  wounds  received  by  employees 
can  be  closed  after  sterihzation  has  been  done.  Many  of  these  cases 
will  require  a  small  rubber  band,  a  wick  of  gauze  or  two  or  three 
strands  of  twisted  silk  gut  for  drainage,  the  same  to  be  removed  after 
twenty-four  or  forty-eight  hours.  The  majority  of  penetrating 
wounds  and  even  the  severe,  crushing  wounds,  after  sterilization, 
the  removal  of  all  foreign  bodies,  and  the  repair  of  the  deeper 
tissues,  can  be  closed  providing  the  doctor  receives  these  cases  early. 
In  many  of  these,  small  drainage  is  often  indicated.  As  a  general 
rule,  the  compound  fractures  should  be  sterilized,  thoroughly  drained, 
and  not  completely  closed.  The  treatment  of  such  wounds,  as 
developed  by  war  surgery,  is  described  under  the  chapter  on  Fractures. 

The  commonest  method  employed  for  the  closure  of  wounds  is 
that  of  suturing  with  catgut,  horsehair,  silkworm  gut,  or  silk  and  linen, 
all  thoroughly  sterilized.  Catgut  is  almost  universally  used  in  the 
repair  of  deeper  tissues.  Some  use  it  in  the  skin  but  a  majority  of 
the  surgeons  prefer  non-absorbable  material.  The  author  has  used  cat- 
gut for  the  closure  of  many  skin  wounds  and  when  iodin  was  used 
religiously,  has  never"  had  any  difficulty  with  infections.  As  a  routine 
measure,  however,  silk,  linen  and  horsehair  are  best  employed  in 
emergency  work. 

During  the  last  five  years,  the  author  has  not  employed  suturing 
in  more  than   10  per  cent,  of  his  cases.     Narrow  strips  of  adhesive 


EMERGENCY    SURGERY 


533 


|j! 

Fig.  78. — Strip  of  adhesive  plaster 
sterilized  with  iodin  at  point  of  con- 
tact with  wound.  Used  in  place  of 
suture. 


plaster  will  coapt  the  skin  edges  of  a  wound  as  thoroughly  as  suturing, 
except  in  those  regions  where  considerable  tension  is  brought  to  bear 
upon  the  skin  as  in  the  movement  of  a  joint.  The  method  for  the 
closure  of  wounds  by  adhesive  plaster  is  as  follows: 

1.  Adhesive  plaster  is  cut  in  one- 
quarter  inch  strips  and  in  lengths 
varying  from  one  inch  to  eight  or  ten 
inches  depending  on  the  location  of  the 
wound. 

2.  That  portion  of  the  adhesive 
plaster  which  comes  in  direct  contact 
with  the  wound  is  thoroughly  painted 
with  tincture  of  iodin  and  allowed  to 

dry.  Care  is  exercised  in  not  touching  the  middle  portion  of  the 
strip  thus  sterilized.     (See  Fig.  78.) 

3.  The  wound  which  has  pre- 
viously been  sterilized  with  tincture 
of  iodin  is  held  together  by  the  sterile 
fingers  of  the  left  hand  while  each 
adhesive  strip,  which  has  previously 
been  attached  to  the  skin  on  one  side 
of  the  wound,  is  drawn  snugly  across 
and  attached  to  the  skin  on  the  other 
side.  Additional  strips  are  thus  ap- 
plied until  the  wound  is  completely 
closed.  A  quarter  of  an  inch  space  is 
left  between  each  strip.  This  allows 
for  the  natural  oozing  of  the  wound. 
(See  Fig.  79.) 

4.  Tincture  of  iodin  is  now  painted 
over  the  adhesive  strips. 

5.  A  sterile  dry  gauze  dressing  is 
placed  over  the  wound  and  adhesive 
strips. 

6.  In  large  wounds  with  consider- 
able gaping  where  it  is  difficult  to 
coapt  the  edges  or  where  tension 
would  ordinarily  indicate  the  use  of 
tension  sutures,  a  small  roll  of  sterile 
gauze  can  be  placed  on  either  side  of 
the  wound  and  a  longer  and  wider 
strip  of  adhesive  plaster  can  be  drawn 

tightly  over  these  so  as  to  cause  inward  pressure  on  the  wound  by  the 
gauze  rolls. 


Fig.  79. — A  cotton  bandage,  cut 
to  the  circumference  of  the  limb, 
edges  bound  with  adhesive  plaster 
into  which  eyelets  are  fixed,  and  a 
tape  for  lacing  affords  a  rapid  method 
of  bandaging. 


534  INDUSTRIAL    MEDICINE    AND    SURGERY 

Adhesive  strips  are  of  no  value  when  moist  dressings  are  to  be 
apphed  to  the  wound. 

The  greatest  value  of  adhesive  strips  over  the  old  method  of  suturing 
is  in  the  psychologic  effect  on  the  employees.  Previously,  workmen, 
especially  foreigners,  would  stay  away  from  the  doctor's  office  for  fear 
their  incised  wound  would  be  stitched.  Some  time  ago  the  author 
overheard  an  employee  who  had  just  received  this  adhesive  plaster 
treatment,  remark  to  a  fellow  employee,  ''Say,  those  docs,  up  there 
are  all  right.  They  don't  butcher  a  fellow  all  up  or  stick  a  needle 
through  every  little  cut  like  that  doctor  at  the  mill  used  to  do.  I  won't 
be  afraid  to  go  up  there  any  more."  Such  favorable  propaganda  as 
this,  spread  throughout  the  working  force,  increases  the  usefulness 
and  value  of  the  doctor's  office. 

Metal  clamps  of  the  Michel  type  are  used  by  some  plant  surgeons 
but  even  when  not  painful,  they  have  an  unfavorable  psychologic 
effect  upon  the  employee. 

The  closure  of  wounds  by  sealing  them  up  with  collodium  is  a 
dangerous  practice.  The  wound  secretions,  clogged  up  under  the 
collodium  dressing,  often  form  a  favorable  seat  for  infection.  One 
foreman  objected  to  his  men  losing  so  much  time  in  going  to  the 
doctor's  office  to  have  minor  wounds  properly  attended  to.  He 
procured  a  bottle  of  hydrogen  peroxid  and  another  bottle  of  col- 
lodium and  some  cotton,  and  proceeded  to  care  for  these  minor  cuts 
and  abrasions  himself.  Two  serious  infections  shortly  occurred 
among  the  employees  treated  by  him.  He  was  not  discharged  but 
the  management  published  his  folly  broadcast  throughout  the  plant 
and  such  individual  efforts  as  these  immediately  ceased.  Further, 
foremen  were  more  keenly  alive  to  the  importance  of  sending  these 
minor  cases  to  the  doctor's  office. 

Great  care  should  be  exercised  in  the  closing  of  wounds  to  prevent 
scar  formation,  especially  on  the  face  or  exposed  portions  of  the  body. 
In  linear  wounds,  the  adhesive  strips  will  cause  healing  with  less  of  a 
scar  than  where  sutures  are  used.  However,  in  jagged  wounds  on  the 
face,  stitches  should  be  employed  in  order  to  secure  less  of  a  scar. 
In  such  cases,  fine  horsehair  is  the  best  material. 

Fainting. — Fainting  is  very  prone  to  occur  during  this  minor 
emergency  surgery.  It  is  best  to  have  patients  he  down  when  their 
wounds  are  being  closed.  If  they  are  allowed  to  sit  up,  they  should 
be  carefully  watched,  and  if  pallor,  clammy  perspiration,  dilated  pupils, 
yawning,  or  a  complaint  of  dizziness  or  blindness  is  made,  they  should 
immediately  lie  down.  Often  when  the  dressing  can  best  be  accom- 
pHshed  by  the  patient  sitting  up,  if  any  of  these  signs  are  noted,  the  faint 
can  be  avoided  by  having  the  patient  lean  over  with  his  head  between 
his  knees.     A  few  whiffs  of  aromatic  spirits  of  ammonia  or  even  a 


EMERGENCY    SURGERY  535 

drink  of  water  will  prevent  many  faints.  Such  patients  should  be 
given  plenty  of  fresh  air.  When  a  person  faints  in  the  dispensary, 
the  other  patients  must  be  carefully  watched  as  frequently  two  or 
three  of  these  may  topple  over.  I  have  seen  several  ugly  scalp  wounds 
received  by  patients  allowed  to  fall  in  faints  and  for  this  reason 
caution  should  always  be  taken  to  prevent  them.  I  have  always 
insisted  that  the  patients  who  faint  in  the  dispensary,  must  lie  down 
for  a  few  moments  in  the  rest  room  before  returning  to  work. 

Immobilization. — The  importance  of  the  immediate  immobiliza- 
tion of  fractures  is  brought  out  in  the  chapter  on  the  same.  For  this 
purpose,  several  different  types  of  splints  should  always  be  on  hand. 

In  severe  incised,  lacerated  wounds  or  crushing  wounds  near 
joints,  the  member  should  be  immobilized  with  a  light  splint  in  order 
to  put  it  absolutely  at  rest.  This  will  not  only  prevent  the  wound  from 
being  torn  open  by  movements  but  is  an  excellent  means  of  preventing 
infection. 

All  sprains  should  be  immobilized.  This  can  be  accomplished  by 
the  use  of  spHnts,  but  often  binding  by  two  or  three  layers  of  adhesive 
plaster  will  afford  the  necessary  rest  for  the  part.  In  applying 
adhesive  plaster  to  the  skin,  all  hair  should  be  carefully  shaved  away. 
It  is  inexcusable  for  any  surgeon  to  apply  adhesive  plaster  over  a 
hairy  area,  even  though  it  be  the  few  hairs  found  around  the  foot 
and  ankle,  and  cause  thereby  the  needless  pain  to  the  patient  when 
the  same  is  removed.  In  some  cases  a  cotton  or  flannel  bandage  can 
first  be  applied  over  the  sprained  joint  and  this  can  then  be  reinforced 
by  adhesive  plaster  strips.  If  swelling  of  the  part  is  anticipated  the 
adhesive   strips  should  not   meet  in  the  middle  line. 

In  extensive  injuries  to  the  soft  parts  of  the  upper  extremity 
both  immobilization  and  rest  can  be  gained  by  the  use  of  the  tri- 
angular sling.  Often,  rest  in  bed  »  ith  sand  bags  placed  on  either  side 
of  the  injured  member,  affords  the  best  method  of  immobihzation  and 
rest.  This  is  well  illustrated  in  the  case  of  hand  infections  where 
immobilization  of  the  entire  upper  extremity  is  very  important  for 
rapid  recovery.  The  patient  should  be  put  to  bed  with  the  arm  ex- 
tended at  an  angle  of  45  degrees  from  the  body.  A  rubber  sheet  is 
placed  under  the  arm  and  hand  to  protect  the  bedding  from  the  moist 
dressings.  A  folded  woolen  blanket  is  placed  under  the  arm  and  hand, 
hot  dressings  are  then  applied  from  the  hand  to  the  elbow,  or  if  in- 
dicated, completely  to  the  axilla.  Sterile  bath  towels  soaked  in  hot 
boric  solution  make  an  excellent  hot  dressing  and  can  be  readily 
wrapped  around  the  entire  arm  and  hand.  The  woolen  blanket  is 
then  folded  over  the  hot  dressings.  Two  or  three  hot  water  bottles 
can  be  placed  about  the  blanket,  and  the  rubber  sheet- is  then  folded 
over  the  entire  dressing  so  that  the  arm  and  hand  are  thoroughly 


536  INDUSTRIAL    MEDICINE    AND    SURGERY 

encased.  This  usually  accomplishes  complete  immobilization  but 
if  necessary,  a  sand  bag  can  be  placed  on  either  side  of  the  member 
to  hold  it  more  securely. 

The  various  things  commonly  used  for  immobilization  are  band- 
ages, adhesive  plaster,  various  sized  pasteboard  or  wooden  splints 
carefully  padded,  plaster  of  paris  splints  or  casts,  blanket  splints, 
pillows  and  specialized  splints  as  the  Hodgen  arm  or  leg  splints, 
or  the  commercial  splints. 

Dressings. — The  rule  "report  to  the  doctor's  office  no  matter  how 
slight  the  injury"  brings  many  cases  with  such  minor  injuries  that  a 
dressing  of  any  kind  is  unnecessary.  The  doctor  should  not  make 
light  of  these  cases  but  carefully  paint  with  iodin  and  explain  to  the 
patient  why  no  dressing  need  be  applied. 


Fig.  80. — A  severe  laceration  of  the  hand  closed  with  adhesive  strips  after  first  steriliz- 
ing the  wound  with  iodin. 

Fifty  per  cent,  of  the  dressings  will  consist  of  a  dry  sterile  gauze 
applied  and  held  in  place  by  a  gauze  bandage.  The  surgeon  must 
remember  that  the  smaller  the  dressing  and  the  fewer  the  joints 
covered  by  same,  the  less  is  the  efficiency  of  the  worker  interfered 
with.  Absorbent  cotton  should  not  be  applied  next  to  wounds  for 
reasons  already  given. 

Moist  dressings  are  chiefly  indicated  in  infected  wounds  or  in 
abrasions  where  they  are  used  to  prevent  the  dressings  from  adhering. 
The  commonest  moist  dressings  are  boric,  saline,  bichlorid  of  mercury 
or  alcohol.  Recently  moist  dressings  of  Dichloramine-T  or  of  the 
Carrel-Dakin  solution  have  been  advocated  by  different  emergency 
surgeons. 

It  is  unwise  to  use  strong  antiseptic  moist  dressings  on  any 
wounds  as  the  adjacent  skin  will  invariably  become  irritated  and  more 
prone  to  infection.  Occasionally  a  physician  will  apply  a  moist 
dressing  of  weak  carbolic  acid  solution  with  the  result  that  when  the 
dressing  is  removed  the  underlying  skin  has  a  characteristic  pallor 


EMERGENCY   SURGERY 


537 


and  the  capillary  blood  supply  is  destroyed.  Or  a  physician  or 
a  patient  may  pour  iodin  on  a  gauze  dressing  and  bind  it  on  the  wound. 
Severe  burns  often  result  from  such  treatments.  In  fact,  iodin  applied 
to  a  wound  should  be  allowed  to  dry  before  applying  the  dressing. 

In  threatened  wound  infections,  especially  about  the  fingers  or 
toes,  and  for  moist  dressings  in  ambulatory  infected  cases,  the  author 
relies  especially  on  equal  parts  of  alcohol  and  glycerin.  For  example, 
the  finger  has  been  punctured.  The  employee  neglects  the  wound 
but  reports  the  next  day  with  the  finger  slightly  swollen,  reddened 
about  the  injury  and  very  tender.  No  sign  of  pus  is  present  and  it  is 
not  indicated  to  open  the  area.     A  fairly  large  pad  of  sterile  gauze 


Fig.  81. — Paraffin  treatment  of  burns:  a,  Sponging  wound  with  Dakin's  solution. 

is  soaked  in  the  alcohol  and  glycerin  and  immediately  wrapped  around 
the  finger.  This  is  covered  with  gutta-percha  so  that  the  dressing 
is  practically  air  tight,  and  is  then  bandaged  in  place.  Such  a  dressing 
is  reapplied  every  twelve  hours.  Usually  by  the  next  day  the 
threatened  infection  has  been  aborted. 

Another  moist  dressing  which  is  very  valuable  especially  in  am- 
bulatory cases  is  composed  of  a  solution  of  magnesium  sulphate  and 
glycerin.  This  is  expecially  adapted  to  abrasions  or  old  chronic, 
ulcerated  areas  where  granulation  must  be  stimulated. 

Dusting  powders  are  chiefly  used  in  abrasions,  small  first  degree 
burns,  or  when  the  skin  has  become  irritated.  Bismuth  subnitrate 
is  the  most  soothing  powder  which  can  be  used.  The  wound  area 
may  be  gently  covered  with  sterile  olive  oil  and  the  bismuth  powder 


538 


INDUSTRIAL    MEDICINE    AND    SURGERY 


applied  over  this.  Bismuth  subiodid,  powdered  oxid  of  zinc,  boric 
powder,  powdered  calomel  and  iodoform  are  powders  most  frequently- 
used  by  surgeons. 


Fig.   82. — Paraffin  treatment  of  burns:  b,  drying  with  hot-air  blast. 


Fig.  83. — Paraffin  treatment  of  burns:  c,  spraying  melted  and  medicated  paraffin  on 

wound. 


Ointments  are  occasionally  applied  to  the  irritated  skin  or  more 
frequently  to  large,  denuded  areas  after  ''weeping"  has  ceased.     Dr. 


EMERGENCY    SURGERY 


539 


A.  I.  Bouffleur  advocates  the  use  of  equal  parts  of  balsam  of  Peru 
and  castor  oil  as  one  of  the  best  ointment  dressings  which  can  be  used 
over  these  chronic,  denuded  areas.  It  stimulates  granulation  and 
prevents  the  dressing  from  adhering.  Chronic  abrasions  over  the 
shin  bone  where  ulceration  so  easily  occurs,  require  such  a  dressing. 
Unguentine,  although  a  proprietary  ointment,  is  one  of  the  most  use- 
ful about  the  dispensary.  It  affords  an  excellent  dressing  for  recent 
abrasions  or  burns  and  also  stimulates  heahng  in  these  chronic  con- 
ditions. Mercurial  ointments,  such  as  white  precipitate,  is  an  excel- 
lent dressing  where  antiseptic  action  is  desired. 


Fig.  84. — Paraffin   treatment   of   burns:  d,    applying   thin    cotton  over   the   paraffin 

film. 

CarboUc  salve  is  chiefly  used  by  the  laymen.  Every  patient  should 
be  warned  against  applying  carboHc  salve  to  a  wound  and  covering 
it  with  a  dressing.  Some  very  serious  cases  of  necrosis  have  followed 
this  practice.  A  girl  employee  scratched  her  little  finger  and  it  be- 
came shghtly  infected.  She  reported  to  the  doctor's  office  where  a 
moist  dressing  was  applied.  That  night  her  mother  removed  the 
dressing  and  put  on  a  large  quantity  of  carboHc  vaseHn,  then  again 
bandaged  the  finger.  She  kept  the  girl  home  the  next  day  under  the 
same  treatment.  The  following  day  the  patient  reported  to  the  doc- 
tor's office  with  the  finger  blanched  and  shriveled.  Within  twenty- 
four  hours,  a  dry  gangrenous  condition  developed  and  continued 
until  the  first  two  joints  of  her  finger  practically  dried  up.  This 
young  lady  has  a  perfectly  useless  fifth  finger  as  a  result  of  the  car- 
bolic ointment. 


540 


INDUSTRIAL   MEDICINE    AND    SURGERY 


The  open  treatment  of  wounds  is  becoming  more  and  more  popular. 
Abrasions  and  burns,  chronic  ulcerated  conditions  and  old  infections 
will  often  yield  more  rapidly  to  this  open  treatment.  A  cage  can 
be  made  from  wire  screening,  the  edges  of  the  cage  being  bound 
with  adhesive.  This  can  then  be  sterilized  with  heat  and  apphed 
over  the  wound.  A  thin  gauze  covering  is  placed  over  the  wire 
cage,  and  adhesive  strips  are  used  to  hold  the  entire  dressing  in 
place.  Free  access  of  air  and  sunHght  seem  to  hasten  the  heaUng 
process. 

Protective  devices  are  often  necessary,  especially  where  employees 
return  to  work  after  the  dressings  are  apphed.  These  consist  of  wood 
spUnts,  tin  sphnts,  wire  cages  and  other  such  measures.  They  are 
usually  retained  in  place  by  the  use  of  adhesive  plaster. 


Fig.  85.- 


-Paraffin  treatment  of  burns:  e,  painting  paraffin  over  the  cotton, 
to  76  from  clinic  of  Dr.  Corwin,  Colorado  Fuel  &  Iron  Co.) 


(Figs.  72 


CONCLUSION 


The  following  points  are  so  vital  in  emergency  surgical  work  that 
their  repetition  is  justified: 

1.  Always  sterilize  open  wounds  no  matter  how  sHght  or  how  ex- 
tensive and  no  matter  where  located.  Tincture  of  iodin  is  the  best 
antiseptic  to  use. 

2.  The  surgeon  must  begin  his  emergency  treatment  immediately 
after  the  accident  occurs. 

3.  The  same  asepsis  must  be  observed  as  in  operative  surgery. 
Only  sterile  dressings  must  be  applied  to  the  wound. 


EMERGENCY    SURGERY  541 

4.  Immediate  immobilization  of  the  injured  member  whenever 
indicated. 

5.  Shock  and  hemorrhage,  whenever  present,  must  receive  first 
consideration. 

6.  Keen  judgment,  carefulness  and  alertness,  adeptness  and 
ingenuity,  and  a  constant  enthusiasm  are  the  necessary  attributes 
of  a  good  emergency  surgeon. 


CHAPTER  XXXIV 

THE  SUBSEQUENT  OR  PERMANENT  TREATMENT  OF 
CERTAIN  INJURIES 

In  previous  chapters  on  industrial  surgery,  consideration  has  been 
given  to  preventive  surgery,  to  first  aid  care,  and  to  the  immediate  or 
emergency  treatment  of  injuries  the  result  of  accidents.  The  remain- 
ing function  of  the  physician  practicing  industrial  surgery  is  to  render 
subsequent  or  permanent  treatment  to  the  injured  employees.  These 
four  functions  are  so  closely  interrelated  that  to  be  a  successful  in- 
dustrial surgeon  one  must  be  expert  in  all  of  these  four  lines.  Some 
of  the  best  surgeons  of  the  country  are  capable  of  doing  excellent  repair 
work  in  accident  surgery  but  would  make  poor  industrial  surgeons 
because  they  are  not  trained  to  think  of  their  surgical  results  in  terms 
of  the  man's  work.  Both  preventive  and  emergency  surgery  are 
based  upon  the  economic  end-results.  The  subsequent  surgery  and 
the  permanent  treatment  involve  the  same  economic  considera- 
tions— the  quickest  possible  recovery,  the  restoration  to  full  func- 
tion or  as  nearly  so  as  is  possible  when  the  nature  of  the  injury  is  con- 
sidered, and  the  placement  at  suitable  work  compatible  with  the 
function  attained. 

The  best  emergency  surgery  is  rendered  in  those  industries  where 
a  surgeon  is  on  the  job  to  give  immediate  treatment  to  every  accident 
case.  The  majority  of  injured  employees  are  able  to  report  to  the 
plant  dispensary  for  their  subsequent  treatment  or  in  the 
absence  of  such  a  dispensary,  to  the  surgeon's  office.  The 
success  of  these  ambulatory  cases  depends  upon  frequent  dressings, 
careful  supervision  to  see  that  the  dressings  are  not  removed  and 
proper  assignment  of  the  injured  to  such  work  as  will  not  delay  the 
healing  process.  Work  is  one  of  the  best  therapeutic  adjuncts  which 
the  surgeon  can  employ  and  in  every  case  he  should  get  the  employee 
back  to  some  occupation  in  the  industry  as  soon  as  possible. 

In  a  certain  number  of  accident  cases,  the  injuries  will  be  so  serious 
as  to  confine  the  employee  to  his  home  or  to  the  hospital  and  arrange- 
ments must  be  made  to  carry  on  the  permanent  treatment  in  one 
or  the  other  of  these  places.  When  subsequent  operations  are  neces- 
sary the  patient  should  always  be  sent  direct  to  the  hospital.  As  a 
general  rule  closer  supervision  can  be  maintained  and  better  results 
obtained  by  rendering  the  permanent  treatment  of  these  serious  injuries 
in   the   hospital   rather  than  in  the   home.     Much   of  the   success 

542 


TREATMENT    OF    INJURIES  543 

of  the  industrial  surgeon  will  depend  upon  his  powers  of  per- 
suading patients  to  accept  this  hospital  care.  The  majority  of  dis- 
satisfied patients  belong  to  those  receiving  home  treatment  and  these 
are  the  ones  who  usually  enter  damage  suits  in  the  courts  or  claim 
excessive  compensation. 

A  few  of  our  largest  industries  have  their  own  hospitals  adjacent 
to  the  plant  where  both  the  emergency  and  permanent  treatment 
can  be  carried  on.  Two  industries  have  a  ward  in  connection  with 
its  doctor's  office  where  the  serious  cases  can  be  kept  for  twenty-four 
or  forty-eight  hours  and  then  removed  to  one  of  the  outside  hospitals 
in  the  community.  In  these  concerns,  the  surgeons  do  most  of  the 
operative  work  at  the  plant,  even  operating  hernia  cases,  and  then 
placing  them  in  the  ward  for  twenty-four  hours.  At  the  end  of  that 
time  they  are  taken  in  an  ambulance  to  one  of  the  city  hospitals. 
This  plan  saves  a  certain  amount  of  expense  to  the  management 
but  is  rather  a  dangerous  procedure  from  the  standpoint  of  the  safety 
of  the  patient. 

As  a  general  rule  major  operative  work  requiring  an  anesthetic 
should  not  be  performed  in  the  plant  dispensary.  Such  work  requires 
considerable  time  and  ties  up  both  the  staff  and  the  doctor's  office 
so  that  the  other  medical  and  surgical  functions  are  neglected.  Again 
it  sometimes  happens  that  a  patient  dies  during  the  anesthetic. 
There  may  be  many  excellent  reasons  for  this  death  but  the  working 
force  always  blames  it  on  the  anesthetic.  The  morale  of  the  employees 
is  lowered  and  their  confidence  in  the  doctor's  office  is  shaken  by 
the  depressing  news  of  a  death  occurring  there.  Years  ago  in  one  in- 
dustrial dispensary  the  surgeon  attempted  to  remove  some  diseased 
tonsils  from  one  of  the  employees.  A  light  anesthetic  was  given 
and  before  the  operation  commenced  the  patient  suddenly  died.  The 
news  of  this  death  spread  rapidly  throughout  the  plant.  Following 
this  accident  it  was  almost  impossible  to  persuade  injured  employees 
to  report  to  this  dispensary  for  treatment.  I  am  told  that  a  drastic 
rule  was  immediately  made  by  the  management  that  no  anesthetic 
should  ever  be  administered  in  the  plant.  In  the  author's  experience 
it  has  only  been  necessary  once  to  give  a  general  anesthetic  at  the 
plant  dispensary.  A  patient  needing  operative  work  requiring  an 
anesthetic  can  usually  be  transferred  to  a  hospital  where  every  facihty 
is  at  hand  to  meet  any  emergency  that  may  arise.  By  careful 
emergency  surgery  and  rapid  evacuation  of  serious  cases  to  an  outside 
hospital,  we  have  been  able  to  avoid  death  in  the  dispensary  for  the 
last  ten  years  and  as  a  result  the  confidence  of  the  working  force 
in  the  doctor's  office  has  never  been  shaken.  Neither  did  any  one  of 
these  patients  die  as  a  result  of  being  moved. 

It  is  very  essential  that  the  best  and  most  up-to-date  hospital 


544  INDUSTRIAL    MEDICINE    AND    SURGERY 

in  the  community  should  be  chosen  for  the  care  of  injured  employees. 
The  surgeon  should  endeavor  to  have  certain  wards  and  private  rooms 
set  aside  in  this  hospital  for  his  cases  and  he  should  become  a  recog- 
nized member  of  the  staff.  Only  in  this  way  can  he  obtain  the  best 
nursing  and  interne  service  for  his  patients,  both  of  which  are  absolute 
essentials  in  accident  surgery.  These  serious  cases  should  not  be 
turned  over  to  a  disinterested  surgeon,  for  employees  are  much  better 
satisfied  if  they  are  in  the  hands  of  a  quaUfied  surgeon  directly  re- 
sponsible to  the  management  of  their  industry.  Such  a  one  becomes 
a  connecting  hnk  between  the  employer  and  employee  and  in  a  hundred 
little  ways  is  able  to  convey  the  personal  interest  of  the  former  to 
his  injured  workmen. 

To  be  successful  the  permanent  treatment  of  these  seriously  in- 
jured employees  must  include:  first,  the  actual  surgical  treatment  and 
subsequent  dressings;  and  second,  the  psychotherapeutic  treatment. 

It  is  not  the  intention  of  the  author  to  write  a  treatise  on  the  sur- 
gical treatment  of  specific  injuries  following  accidents,  but  rather  to  deal 
with  certain  general  principles  involved  in  industrial  surgery.  Many 
standard  surgical  works  and  such  books  as  Foote's  "Emergency  Sur- 
gery," Moorhead's  "Traumatic  Surgery,"  Cotton's  book  on  "Frac- 
tures and  Dislocations,"  and  other  of  the  more  recent  writings  on  war 
surgery,  will  give  the  student  the  necessary  information  on  special 
lines  of  treatment. 

The  psychotherapeutic  treatment  of  the  injured,  however,  has 
been  woefully  neglected  by  the  majority  of  surgeons,  and  consideration 
of  this  important  phase  of  the  care  of  injured  employees  is  indicated. 

The  psychology  of  a  workman  who  has  received  injuries  the  result 
of  his  employment,  is  pecuhar  and  has  an  important  bearing  on  the 
successful  outcome  of  the  treatment.  In  the  first  place,  he  feels  that 
his  employer  is  responsible  for  his  suffering  and  disabihty  and  should 
be  made  to  pay  dearly  for  the  same.  He  is  then  forced  to- accept  the 
administrations  of  a  surgeon  chosen  by  this  employer  rather  than  by 
himself  or  his  family.  He  is  carried  directly  to  a  hospital  and  if 
conscious,  usually  frets  a  great  deal  over  how  the  news  of  his  accident 
will  be  broken  to  his  wife  or  family.  His  surroundings  are  strange, 
the  experience  is  entirely  new  and  he  is  in  the  hands  of  strangers.  An 
immediate  operation  may  be  necessary  and  how  does  he  know  whether 
the  doctor  will  amputate  the  injured  member  or  otherwise  leave 
him  permanently  disabled.  In  case  of  such  permanent  disability,  how 
will  he  ever  make  a  hving  again  and  what  will  become  of  his  family? 
These  and  a  thousand  other,  fears  prey  on  his  mind  and  unless  im- 
mediately dispersed  by  the  surgeon  may  interfere  with  his  recovery. 

During  the  days  and  weeks  which  follow,  such  a  patient  can  easily 
become  discouraged  or  dissatisfied  and  as  a  result  he  develops  a  neuro- 


TREATMENT    OF    INJURIES  545 

sis  which  usually  greatly  delays  his  recovery.  If  his  daily  dressings 
are  extremely  painful,  another  factor  for  the  development  of  neurosis 
is  introduced.  Or  if  pain  and  discomfort  accompany  the  use  of  an 
injured  member  he  may  resist  all  efforts  to  regain  function  in  the  part 
and  delay  of '  this  kind  frequently  results  in  permanent  disability. 
During  these  days  while  lying  in  bed  slowly  recovering,  his  mind  will 
have  time  to  dwell  upon  the  thoughts  of  compensation.  The  desire 
for  excessive  compensation  may  become  so  great  as  to  cause  him  to 
feign  certain  conditions,  while  in  other  cases  he  may  resist  all  efforts 
for  a  rapid  recovery  in  order  to  receive  his  weekly  compensation  over 
a  longer  period.  This  latter  is  often  the  case  when,  in  addition  to  his 
accident  compensation,  he  is  receiving  benefits  from  his  lodge  or  union. 

All  of  these  various  mental  states  play  such  an  important  part  in 
the  recovery  of  these  injured  employees  that  the  industrial  surgeon 
must  constantly  be  on  the  alert  to  counteract  their  influence.  With 
this  in  mind,  let  us  consider  the  various  methods  necessary  to  meet 
these  conditions. 

Better  results  can  be  obtained  if  the  surgeon  employed  by  an  in- 
dustry, providing  he  is  capable,  takes  complete  charge  of  every  accident 
case.  In  the  majority  of  instances  when  employees  choose  their  own 
doctor,  their  period  of  disability  is  prolonged  and  the  functional  re- 
sults are  not  uniformly  good.  On  the  other  hand,  if  the  employer 
arbitrarily  chooses  the  surgeon  for  his  employees,  he  should  pick  one 
whom  he,  himself,  would  trust  in  every  emergency.  The  reputation 
of  such  a  surgeon  soon  spreads  throughout  the  working  force  so  that 
when  an  employee  sustains  a  serious  injury,  his  confidence  in  the 
doctor  is  already  estabHshed.  The  surgeon,  however,  must  endeavor 
to  gain  the  complete  confidence  of  every  injured  workman  from  the 
very  minute  he  takes  charge  of  the  case. 

EstabUshing  confidence,  therefore,  is  the  first  link  in  the  psycho- 
therapeutic care.  If  the  surgeon  enters  the  dressing  room  without 
paying  much  attention  to  the  patient,  becomes  excited  at  the  sight  of 
the  wound,  and  cries  out  orders  and  counterorders  to  his  assistants, 
starts  one  line  of  treatment  then  switches  to  another,  handles  the 
injured  member  roughly  or  otherwise  causes  unnecessary  pain,  he 
soon  has  the  patient  and  all  those  about  him  completely  bewildered. 
On  the  other  hand,  if  the  surgeon  takes  time  to  speak  to  his  patient 
while  sizing  up  the  extent  of  his  injury,  learns  the  patient's  first  name 
and  addresses  him  by  it,  cheers  him  up  and  endeavors  to  overcome  any 
antagonism  which  may  exist,  then  gently  but  deftly  renders  the  neces- 
sary treatment,  quietly  issuing  liis  orders  to  his  assistants,  he  im- 
mediately establishes  an  atmosphere  of  calmness  and  efficiency  which 
impresses  and  reassures  the  injured.  Such  a  surgeon  is  not  only  the 
mechanic  called  in  to  repair  the  broken  parts  but  at  once  becomes  a 

35 


546  INDUSTRIAL    MEDICINE    AND    SURGERY 

friend  and  that  confidence  between  doctor  and  patient,  so  necessary 
in  accident  surgery,  is  established. 

Reassuring  the  patient  that  his  wounds  are  not  as  serious  as  he 
may  think  must  be  stated  as  soon  as  the  surgeon  has  had  the  op- 
portunity of  inspecting  the  condition.  The  more  serious  the  wound  the 
more  essential  it  is  for  the  surgeon  to  smile  and  not  betray  by  the  least 
sign  his  fears  of  a  fatal  outcome.  Such  remarks  as  "internal  injuries," 
''high  amputations,"  ''gangrene,"  and  other  equally  terrifying  terms 
should  not  be  made  in  the  presence  of  the  injured.  If  the  friends  or 
relatives  excite  the  patient  they  should  be  kept  from  the  room.  While 
combating  death  with  your  every  effort,  if  the  patient  is  conscious, 
cheerfully  reassure  him  and  stimulate  him  to  put  up  a  fight. 

Notifying  the  relatives  about  the  accident  must  be  thought  of  at 
once.  No  employee  should  be  taken  to  the  hospital  without  im- 
mediately sending  someone  to  notify  his  family.  No  worse  seeds  of 
dissatisfaction  can  be  sown  than  to  leave  the  wife  worrying  all  night 
over  the  non-appearance  of  her  husband  after  his  day's  work,  or  even 
allowing  several  hours  to  elapse  before  notifying  her.  The  author 
trained  two  of  his  nurses  in  the  best  and  most  tactful  way  of  approach- 
ing the  family  and  telling  them  of  the  injury.  These  nurses  were 
given  the  authority  to  call  a  taxicab  whenever  necessary  and  bring 
the  wife  or  other  members  of  the  family  to  the  hospital  as  soon  as 
possible.  By  the  time  the  wife  has  reached  the  hospital  such  a  nurse 
usually  has  her  trained  to  approach  the  husband  without  unduly  ex- 
citing him.  Surgeons  who  neglect  the  family  miss  their  greatest 
opportunity  of  establishing  friendly  relations  with  the  patient. 

Explaining  the  whys  and  wherefores  of  every  step  in  the  treatment 
of  his  case  is  the  best  means  of  securing  the  co-operation  of  the  patient. 
If  a  part  must  be  amputated  explain  the  reasons  to  the  patient  and 
show  him  the  futility  of  endeavoring  to  save  the  member.  On  the 
other  hand,  if  there  is  a  possibihty  of  saving  the  part  and  yet  later  it 
may  become  necessary  to  amputate,  explain  the  condition  and  get 
him  interested  in  the  fight.  If  it  becomes  necessary  to  amputate 
two  weeks  later,  he  will  fully  understand  the  delay  and  will  not  criti- 
cise you  for  neglecting  to  operate  at  once. 

Avoid  unnecessary  pain  during  the  daily  dressings.  When  severe 
pain  is  inevitable  the  surgeon  should  employ  nitrous  oxid  gas  during 
the  dressing.  This  anesthetic  can  be  administered  similar  to  the  use 
of  gas  in  an  obstetrical  case.  Such  details  hasten  the  recovery  and  win 
the  everlasting  gratitude  of  the  patient. 

Study  the  mental  attitude  of  the  patient  and  strive  to  overcome 

all  those  stimuli  for  the  development  of  traumatic  neuroses.     If  the 

.  man  is  fussy  and  given  to  complaining  it  may  be  necessary  to  coddle 

him.     Again,  such  a  patient  may  best  be  treated  by  the  surgeon  taking 


TREATMENT   OF   INJURIES 


547 


a  firm  stand  and  scolding  him;  and  in  still  others,  this  mental  state  may 
be  overcome  by  carefully  explaining  its  effect  on  the  final  recovery. 
Every  injured  employee  has  his  moods  and  each  must  be  handled 
individually. 

Mental  idleness  is  the  greatest  drawback  to  a  quick  recovery.  The 
patient  who  lies  all  day  with  nothing  to  do  has  time  to  worry  and 
become  dissatisfied.  Therefore,  the  surgeon  must  counteract  in  every 
case  this  mental  idleness.  Bedside  and  ward  occupations  are  the  best 
means  of  accomplishing  this.  In  the  past,  nurses  have  realized  that 
their  patients  are  better  satisfied  and  require  less  personal  attention 
if  they  are  employed,  and  so  have  given  them  light  duties  to  perform, 


Fig.  86. — Incline  in  the  Minnequa  hospital.  (Grade  1  foot  in  6.)  Serviceable 
for  the  sick  and  lame.  Can  also  be  used  for  giving  graduated  exercises  to  heart  cases 
and  other  convalescents.     {Colorado  Fuel  &  Iron  Co.) 

such  as  rolhng  bandages,  preparing  dressings,  making  appHcators  and 
other  light  or  useful  employment.  The  busy  surgeons  have  neglected 
this  form  of  psychotherapy.  The  author  has  been  in  the  habit  of 
learning  the  exact  occupation  of  each  of  his  patients  and  then  tactfully 
stimulating  him  to  study  and  work  along  lines  which  will  improve  his 
status  on  returning  to  his  job.  I  have  found  many  of  these  patients 
greatly  interested  in  improving  their  education  during  the  long  days  of 
convalescence.  Some  who  have  not  had  the  opportunity  of  going  to 
school  will  welcome  the  chaince  of  studying  the  three  R's.  Others  will 
enter  into  the  study  of  chemistry  or  of  stenography,  bookkeeping, 
commercial  lines  and  similar  studies,  and  will  develop  ambitions 
during  these  days  of  convalescence  which  they  never  dreamed  of  before. 


548 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Still  other  patients  will  respond  more  readily  to  manual  diversions. 
They  will  spend  hours  working  over  puzzles  or  at  basketry  or  at 
weaving,  or  even  playing  games  with  some  fellow  patient.  In  many 
instances  I  have  found  problems  connected  with  their  occupation  in 
the  plant,  have  brought  these  problems  to  them  and  have  suggested 
that  they  might  improve  their  standing  as  an  employee  by  working  out 
some  improved  method  during  these  days  of  idleness.  Many  of  these 
employees  will  take  a  draughting  board,  drawing  paper  and  pencil,  and 
with  rulers  and  compasses  will  study  out  many  ingenious,  often  im- 
practical, contrivances.  The  chief  point  is  that  they  have  become 
interested  in  Ihoir  work  and  are  anxious  to  return  to  the  job  in  order, 


Fig.  87. — Aiuputation  case  learning  typewriting  during  his  stay  in  the  liospital. 
pliance  on  typewriter  enables  making  of  duplicate  copies. 


Ap- 


to  try  out  some  of  these  experiments.  When  an  employee  has  lost  an 
arm  or  a  leg  or  even  an  eye  as  a  result  of  his  accident,  he  is  greatly 
discouraged  and  feels  that  his  future  is  damned.  A  good  surgeon  will 
immediately  conceive  methods  of  awakening  ambition  in  such  patients. 
If  they  cannot  return  to  their  old  job  he  will  suggest  lines  of  study  or 
work  which  will  prepare  them  for  a  better  position  in  some  aUied 
occupation.  The  employer  can  often  be  interested  in  these  efforts  and 
will  be  of  the  greatest  help  in  suggesting  the  means  of  preparing  the 
patient  for  his  future. 

This  rehabilitation  of  injured  employees  is  one  of  the  most  fertile 
fields  of  endeavor  open  to  the  surgeon.     Every  hospital  should  provide 


TREATMENT    OF    INJURIES 


549 


some  qualified  person  who  can  assist  in  these  forms  of  psychotherapy. 
Often  the  manual  work  which  is  given  the  patient  will  be  such  as  will 
help  him  to  regain  function  in  an  injured  member.  For  instance,  con- 
tractures following  a  hand  infection  often  result  in  stiff  and  useless 
fingers.  Early  employment  of  the  fingers  by  typewriting,  by  weaving, 
by  grasping  a  hammer  or  a  saw,  and  similar  methods  will  be  of  the 
greatest  aid  in  preventing  undue  contraction  and  restoring  function. 


OCCUPATIONAL  THERAPY 


This  use  of  work  as  a  means  to  help  restore  function  and  as  an 
adjunct  to  the  usual  surgical  treatment,  employed  as  a  form  of  psycho- 


FiG.  88. — An  amputation  <;ase  learning  to  use  his  stump  by  doing  wood-carving. 


therapy,  is  called  occupational  therapy.  It  can  be  used  during  the 
hospital  treatment  or  the  home  treatment  as  above  described.  Small 
shops  should  be  estabhshed  in  connection  with  each  hospital  where 
various  kinds  of  occupational  therapy  can  be  administered. 

As  soon  as  possible,  however,  patients  should  be  removed  from  the 
influence  of  the  hospital.  Every  surgeon  knows  the  great  patience 
and  time  that  is  often  required  to  overcome  the  hospitalization  which 
follows  a  prolonged  sojourn  there.  But  patients  leaving  the  hospital 
and  allowed  to  remain  in  idleness  around  the  home  frequently  develop 
even  a  worse  state  of  mind.     Therefore,   as  soon  as  possible  after 


550  INDUSTRIAL    MEDICINE    AND    SURGERY 

leaving  the  hospital  every  injured  employee  should  be  returned  to 
some  light  occupation  in  the  plant.  Foremen  must  realize  that  this 
is  a  definite  part  of  the  treatment  and  that  such  employees  are  not 
expected  to  turn  out  an  average  day's  work. 

To  successfully  carry  on  such  occupational  therapy,  industries 
would  find  it  greatly  to  their  advantage  to  establish  schools  and  ex- 
perimental shops  in  some  portion  of  the  plant  where  every  injured 
man,  or  woman,  could  spend  the  days  of  convalescence  in  some  form 
of  occupation.  This  would  not  only  hasten  recovery  but  would  make 
a  better  employee  when  he  returns  to  work.  Every  efficient  manage- 
ment is  anxious  to  fill  the  better  positions  in  the  plant,  such  as  foremen, 
chief  clerks,  etc.,  from  the  ranks  of  its  working  force.  Many  foremen 
and  future  managers  could  be  developed  in  these  schools  and  shops 
maintained  for  injured  employees. 

The  following  example  illustrates  to  what  extent  light  occupations 
about  the  plant  can  be  employed  by  the  surgeon  to  assist  in  restoring 
function  to  disabled  parts. 

C.  W.,  forty,  male,  Polish  nationality,  was  severely  burned  about 
his  right  arm,  right  leg  and  back.  After  three  months  the  wounds 
had  healed  but  wound  contractures  were  threatening  to  cause  perma- 
nent deformities.  During  his  stay  in  the  hospital  this  patient  was 
given  passive  motion  and  as  soon  as  possible  active  motion,  and 
certain  work  and  exercises  to  prevent  these  contractures.  In  spite 
of  these  precautions  the  right  knee  had  considerably  flexed  and  the 
right  wrist  was  greatly  restricted  in  motion.  During  this  period 
of  his  disability,  C.  W.  had  received  his  full  weekly  wage  from  the 
concern.  Arrangements  were  now  made  for  his  return  to  light  work 
as  we  recognized  that  he  was  neglecting  to  exercise  these  parts  while 
remaining  at  home.  The  patient  objected  to  returning,  however,  and 
so  it  was  explained  to  him  that  from  that  time  on  he  would  only  receive 
two-thirds  of  his  wages  which  was  the  amount  required  by  the  compen- 
sation law.  On  the  other  hand,  if  he  would  return  to  light  work  for  a 
few  hours  every  day  at  first,  he  would  continue  to  receive  his  full  wages. 
This  argument  as  usual  prevailed  and  C.  W.  reported  for  duty.  He 
was  given  a  light  paint  brush  and  a  bucket  of  paint  and  assigned  the 
task  of  painting  the  steam  pipes  and  radiators.  In  order  to  do  this, 
it  was  necessary  for  him  to  ascend  four  steps  on  a  ladder  while  painting 
the  overhead  pipes,  then  he  stood  on  the  floor  for  a  portion  of  the  time 
and  in  order  to  paint  the  pipes  near  the  floor  he  was  forced  to  stoop 
and  bend  the  knee.  At  first  he  persisted  in  using  his  left  hand  in 
wielding  the  paint  brush  but  the  surgeon  got  him  interested  in  the 
game  and  bound  up  the  left  hand  so  that  it  was  impossible  to 
hold  the  brush.  Naturally  he  was  very  awkward  during  the  early 
days  and  accomplished  very  Httle  work  but  gradually  he  began  to 


TREATMENT    OF    INJURIES  551 

use  the  wrist  and  knee  more  and  more.  After  one  month  the  knee 
was  perfectly  straight  and  could  be  flexed  or  extended  at  will.  It 
took  three  months  to  restore  perfect  function  in  the  wrist  but  at  the 
end  of  that  time  C.  W.  was  an  expert  painter  and  the  management 
decided  to  keep  him  permanently  on  this  job.  His  wages  were  in- 
creased commensurate  with  this  work,  whereas  before  the  accident 
he  had  been  a  day  laborer  about  the  power  plant  earning  some  $16.00 
a  week.  He  had  now  learned  a  trade  and  for  the  first  time  in  his  life 
had  developed  an  ambition.  When  at  the  end  of  three  months  he 
received  his  first  weekly  pay  check  for  $22.00,  C.  W.'s  Americanization 
was  completed  and  he  began  at  once  planning  to  buy  his  own  home. 
Two  years  later  this  employee  told  the  surgeon  that  his  accident 
was  the  best  thing  that  had  ever  happened  to  him. 

PHYSIOTHERAPY 
Massage,  Hydrotherapy,  Electrotherapy 

Industrial  surgeons  as  well  as  all  others  have  devoted  almost  their 
entire  attention  to  standardize  surgical  methods  and  have  neglected 
many  of  the  therapeutic  adjuncts  which  are  of  the  greatest  assistance 
in  restoring  function  and  securing  rapid  recoveries.  The  idea  of  bed- 
side occupations  and  later  the  application  of  occupational  therapy  as 
described  above  has  developed  during  the  last  few  years  and  has  lately 
been  especially  stimulated  by  the  reconstruction  of  disabled  soldiers 
in  the  European  and  Canadian  hospitals  and  now  in  our  own  hospitals. 
The  use  of  massage,  electricity  and  the  various  forms  of  hydrotherapy 
as  definite  therapeutic  methods  have  been  known  for  years  but  these 
excellent  means  have  been  left  chiefly  to  a  few  enthusiasts  in  the 
profession  or  have  been  relegated  to  the  realms  of  quackdom.  Many 
a  surgeon  has  been  chagrined  by  having  a  patient  over  whom  he  has 
labored  for  months,  seek  relief  at  the  hands  of  some  osteopath  or  other 
type  of  physiotherapist,  and  return  to  him  completely  cured  in  the 
course  of  a  month.  The  reason  for  this  is  that  the  surgeon 
has  depended  entirely  on  the  old  classical  Hues  of  treatment  taught 
him  in  medical  school  and  failed  to  take  advantage  of  some  of  these 
most  excellent  methods  used  by  the  other  man.  Instead  of  condemn- 
ing these  therapeutic  measures  because  they  are  used  chiefly  by  the 
so-called  quack,  we  should  condemn  those  practitioners  who  claim  a 
cure-all  by  these  means.  The  whole  field  of  physiotherapy  has 
played  such  an  important  part  in  the  surgical  work  during  this  great 
war  that  these  methods  will  undoubtedly  become  a  definite  part  of  the 
therapy  practiced  by  surgeons  in  the  future. 

Major  R.  Tait  McKenzie,  M.  D.,  professor  of  physical  training 
at    the    University    of    Pennsylvania,    has    covered   this   field   very 


552  INDUSTRIAL    MEDICINE    AND    SURGERY 

thoroughly  in  a  book  entitled  "Reclaiming  the  Maimed."  Every 
industrial  surgeon  should  become  familiar  with  the  methods  therein 
described.  Under  many  different  conditions  he  points  out  the  great 
value  of  massage,  hydrotherapy  and  electrotherapy  as  a  definite 
part  of  the  permanent  treatment. 

For  instance,  in  the  case  of  injuries  to  peripheral  nerves,  all  the 
way  from  bruising  of  a  nerve  trunk  to  its  destruction  and  restoration 
by  surgical  means,  he  states:  ''These  cases  are  accompanied  by 
weakness,  or  paralysis,  muscular  wasting,  and  contractures.  They  are 
treated  by  wet  or  dry  heat  to  exalt  the  local  circulation;  supported  in 
proper  position  by  splints  to  prevent  the  overstretching  of  weakened 
muscles,  and  the  resultant  permanent  contraction  of  those  that  are 
unimpaired ;  galvanic,  and  afterward  faradic,  stimulation  to  the  affected 
muscles;  massage  to  keep  up  or  improve  their  nutrition;  passive  move- 
ment to  prevent  contraction  and  limitation  of  the  normal  range  of  the 
joint;  progressive  active  movement,  joint  by  joint,  to  bring  back  and 
strengthen  voluntary  power;  ending  with  gymnastic  and  occupational 
therapy  for  skill  to  fit  the  patient  to  take  his  place  in  civil  life  again." 

In  regard  to  scar  tissue  with  contractures  and  in  extensive  scar 
tissue  following  old  septic  wounds,  McKenzie  says:  ''Such  wounds 
are  treated  by  the  warmth  of  the  whirlpool  bath,  which  in  twenty 
minutes  changes  the  cold  purple  of  the  painful  hand  into  a  warm 
crimson,  and  enables  the  masseur  to  stroke,  knead,  and  move  a  joint 
in  a  way  that  no  amount  of  persuasion  would  have  made  tolerable 
without  it. 

"The  hastening  of  repair  in  these  scars  by  diathermy  and  ionization 
and  the  stretching  of  beginn'ng  contractures  by  careful  manipulation, 
taking  care  to  avoid  the  breaking  down  of  scar  tissue  in  course  of 
organization,  are  among  the  triumphs  of  these  methods." 

This  war  has  greatly  increased  our  knowledge  of  functional 
neuroses  and  many  a  surgeon,  as  a  result  of  his  war  experience,  has 
developed  the  necessary  patience  to  successfully  handle  these  cases. 
These  neuroses  take  the  form  of  paralysis,  contractures,  areas  of 
anesthesia  or  hyperesthesia,  loss  of  sight,  speech  or  hearing  and  many 
other  pecuhar  phenomena.  Many  miraculous  cures  have  already 
been  accomplished  by  our  physiotherapists  working  in  the  war  hospi- 
tals. In  these  cases  massage,  hydrotherapy  and  electro-therapy 
combined  with  the  personaHty  of  the  operator  furnish  a  combination 
of  hypnotism,  suggestion  and  encouragement  and  results  in  the  cure 
of  many  conditions  which  would  not  otherwise  yield  to  the  ordinary 
treatment.  Unfortunately  thousands  of  soldiers  will  be  thrown  back 
into  civil  life  who  have  been  cured  by  this  form  of  physiotherapy 
and  they  will  more  than  ever  before  depend  on  these  methods  as 
eure-a!ls  for  every  condition.     "Quacks"  will  take  advantage  of  this 


TREATMENT    OF    INJURIES 


553 


to  extend  their  profiteering  on  the  human  credulity.  In  order  to 
prevent  this,  surgeons  must  standardize  these  methods  and  apply 
them  in  every  case  where  they  can  hasten  or  assist  recovery. 

Several  industrial  surgical  dispensaries  have  already  adopted  these 
methods.  A  quahfied  masseur  is  employed  on  the  medical  staff  to 
give  massage  under  the  direction  of  the  surgeon.  Arm  baths  and  leg 
baths  have  been  added  to  the  equipment  of  the  dispensary  where 
hot  and  cold  hydrotherapy  can  be  administered  when  necessary. 
McKenzie  advocates  the  whirlpool  bath  in  all  cases  of  painful  stumps, 
painful  scar  tissues,  partial  paralysis,  injuries  to  nerves  and  to  any 
condition  which  lowers  the  circulation  and  nutrition  of  the  part. 

"The  arm  or  leg  is  thrust  into  a  vessel  containing  water  at  a 
temperature  varying  from    105   up   to    115  degrees.     This  water  is 


Fig.  89. — Adjustable  electric  cabinets  suitable 
for  local  heat  bath.      (Burdick.) 


Fig.  90. — Same  as  Fig.  89. 


circulated  by  means  of  jets  set  at  an  angle  or  by  a  propeller.  Air 
is  also  introduced,  so  that  the  limb  is  immersed  in  a  swirhng,  bubbling 
current.  In  this  way  the  part  is  flushed  with  blood,  and  the  full  effect 
of  heat  is  obtained  in  a  way  that  is  impossible  if  the  water  is  still." 
The  author  has  recently  used  radiant  light  and  heat  in  the  treat- 
ment of  strains,  backaches,  muscle  pains  and  other  conditions  of 
obscure  origin  but  undoubtedly  having  a  neurotic  basis.  Such  cases 
report  to  the  doctor's  office  frequently  and  continue  to  report  for 
days  and  weeks  complaining  of  the  pain  which  does  not  yield  to  the 
ordinary  methods.  If  such  patients  receive  proper  attention  the  first 
day  they  report  and  are  put  in  the  rest  room  and  given  a  course  of 
treatment  with  the  radiant  heat  followed  by  massage,  the  condition 
is  usually  cured  at  once,  or  within  two  or  three  treatments,  thus 
saving  these  cases  much  loss  of  time  from  work  and  the  accompanying 
inefficiency    which  goes  with  such  conditions.     Figures  89  and  90 


554 


INDUSTRIAL   MEDICINE    AND    SURGERY 


illustrate  two  types  of  local  light  and  heat  baths  which  can  be  used 
in  the  surgical  dispensary. 

Dr.  B.  F,  Lounsbury  in  his  railroad  accident  surgery  at  the  Wash- 
ington Boulevard  Hospital,  Chicago,  keeps  a  physiotherapist  in 
constant  attendance  at  the  hospital.  In  practically  all  major  acci- 
dent cases  he  employs  faradic  and  galvanic  electricity,  heat  and 
light  baths,  hydrotherapy,  massage  and  gymnastic  exercises  as  a 
definite  means  of  restoring  function  and  hastening  recovery.  All 
these  methods  can  be  applied  in  the  large  industrial  dispensary  and 
the  results  obtained  justify  the  additional  expense. 


FUNCTIONAL  RE-EDUCATION  ^ 

Functional  re-education  aims  at  the  restoration  of  lost  or  restricted 
function  in  a  disabled  member.     It  is  based  upon  the  principle  of 


Fig.  91. — A  hospital  bed  with  frame  and  sling  attached.     This  enables  patient  to  move 
himself  and  facilitates  exercising  in  bed. 

letting  each  patient  be  his  own  doctor.     During  the  early  days  of 
convalescence  an  operator  must  give  the  massage  and  passive  move- 


TREATMENT   OF   INJURIES 


555 


ments  necessary  to  prevent  complete  loss  of  function,  but  as  soon  as 
possible  active  movements  by  free  exercise  or  with  apparatus  should 
be  instituted  in  order  that  the  patient  himself  can  re-educate  the  part 
and  cultivate  strength  and  endurance.  This  re-education  can  be  made 
so  interesting  for  the  patient  that  it  takes  his  mind  off  of  the  dis- 
ability and,  therefore,  has  an  excellent  psychotherapeutic  value. 

While  a  limb  is  still  in  a  splint,  or  otherwise  immobilized,  a  patient 
may  learn  certain  muscle  resisting  exercises  by  a  process  of  mental 
control  over  different  groups  of  muscles.  In  this  way  muscle  twitch- 
ing without  moving  the  joint  can  be  commenced  weeks  before  the 
splint  is  removed.  When  final  and  free  motion  of  the  joint  can  begin, 
the  muscles  having  become  strong  instead  of  atrophied,  the  patient 


Fig.  92. — A  bed  table  suitable  for  games  or  bed-side  occupations. 

Corwin.) 


{Courtesy  of  Dr. 


is  able  to  raise  the  dropped  wrist  or  to  bend  the  stiffened  knee.  The 
period  of  disability  can  be  greatly  reduced  by  this  type  of  functional 
re-education. 

The  greatest  value  of  functional  re-education,  however,  is  found  in 
those  cases  of  scar  contracture,  stiff  joints  following  long  spUntage 
or  following  extensive  injuries  with  scar  formation,  in  paralysis  follow- 
ing injuries  of  the  nerves  or  in  those  cases  of  lost  tendon  and  muscle 
tissue.  The  value  of  occupational  therapy  as  a  form  of  functional 
reeducation  has  already  been  pointed  out  and  wherever  it  can  be  ap- 
plied in  a  practical  way  it  is  certainly  of  more  value  than  any  other 
form.  However,  during  the  hospital  days  and  the  convalescent  period 
before  the  patient  is  able  to  take  up  practical  work  this  reeducation 
can  be  greatly  facilitated  by  the  use  of  certain  appliances. 


556 


INDUSTRIAL    MEDICINE    AND    SURGERY 


-»"--C-^-- 


1^  MECHANOTHERAPY 

The  use  of  apparatus  for  functional  re-education  is  called  mechano- 
therapy. Its  principles  are  best  described  by  Dr.  McKenzie  who  has 
invented  several  different  types  of  apparatus  which  are  now  in  use  in 
practically  all  the  Canadian  war  hospitals  and  several  of  the  army 
hospitals  in  this  country. 

"Apparatus  is  necessary  to  bridge  the  gap  between  free  movement 
and  the  more  complicated  and  skillful  co-ordination  of  gymnastics  and 

occupation,  and   it  can  be  constructed  so 
as   to    give   a   graduated   and   measurable 

i'S,,^  load,  to  be  increased  as  strength  returns. 

N.  Muscles  work  better  against  resistance  than 

free,  and  the  necessary  resistance  may  be 
given  by  the  hand,  by  friction,  forming  a 
brake  on  the^  turning  of  a  wheel  or  handle, 
by  stretching  elastic  cords,  or  by  stretching, 
or  compressing  springs.  In  these  devices, 
it  is  difficult  or  impossible,  to  measure 
accurately  the  work  done.  They  vary  at 
different  stages  of  the  movement,  are  un- 
even, and  the  patient  quickly  tires  and 
becomes  discouraged,  because  he  cannot 
see  a  definite  and  measurable  improvement. 
The  best  principle  to  use  is  the  raising  of 
graduated  weights,  either  by  a  lever  or  by 
a  rope  and  pulley.  In  the  former,  the 
weight  is  clamped  on  a  lever  at  points  in- 
dicated on  a  scale,  the  lengthening  of  the 
lever  increasing  the  force  necessary  to  raise 
it.  This  is  the  principle  employed  by 
Zander  in  most  of  his  machines,  which, 
however,  are  expensive,  complicated, 
cumbrous,  require  much  space,  and 
need  an  engine  to  supply  motive  power 
for  some  of  them.  Appliances  can  be 
constructed  to  produce  accurately  the 
same  effects  at  one-tenth  the  cost,  by  making  use  of  the  weight  and 
pulley. 

"  Figure  93  shows  diagrammatically  an  arrangement  by  which  the 
direction  of  the  resistance  may  be  upward,  downward,  or  from  the 
s'de.  Machines  combining  these  three  movements  are  called  triplex, 
or  triplicate  machines,  but,  in  addition  to  these,  special  devices  are 
necessary  for  exercising  certain  joints.     The  following  set  of  appli- 


FiG.  93. — The  triplicate 
pulley  weight.  (McKenzie, 
"Reclaiming  the  Maimed."  The 
Macmillan  Co.,  Publishers.) 


TREATMENT   OF   INJURIES  557 

ances  are  designed  to  combine  simplicity,  cheapness,  and  efficiency. 
They  can  be  easily  multipHed  to  any  extent  by  a  good  carpenter  and 
blacksmith  who  has  the  pattern  before  him. 

"Their  use  should  have  a  place  in  a  definite  sequence;  treatment 
begins  with  the  preparation  of  the  limb  or  joint  by  electricity,  radiant 
heat,  or  hot  baths,  then  massage  and  passive  movements,  as  already 
described,  followed  by  active  movement.     A  mirror  is  of  great  value 


Fig.  94. — Protractors  for  measuring  angles  of  movement  in  the  shoulder,  elbows, 
wrist,  knee  and  ankle.  Hart  House.  (McKenzie,  "Reclaiming  the  Maimed.")  The 
Macmillan  Co.,  Publishers. 

to  teach  accuracy  and  associate  the  feeling  of  the  movement  with  its 
appearance. 

"Before  beginning  the  re-education  of  a  joint,  the  range  of  move- 
ment should  be  carefully  measured.  This  is  done  by  means  of  pro- 
tractors of  cardboard,  or  galvanized  sheet  iron,  with  the  scale  marked 
in  degrees.  The  illustration  shows  the  method  of  measuring  move- 
ments of  the  shoulder  forward  and  backward,  the  protractor  being 
set  with  zero  perpendicular  to  the  joint  as  checked  by  a  plumb  Hne. 
The  movement  in  either  direction  is  marked  in  degrees.  The  elbow, 
wrist,  knee,  and  ankle  are  measured  by  the  second  protractor  made 


558 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Fjg_  95. — Adduction  and  abduction  of  wrist.     Note  the  scale  to  measure  the  angle  of 
movement.     {From  McKenzie,  "Reclaiming  the  Maimed.") 


Fig.  96.— Measuring  atreugtli  of  grip  by  the  tycos  sphygmomanometer.     F.  W.  Harvey. 
{From  McKenzie,  "Reclaiming  the  Maimed.") 


TREATMENT    OF    INJURIES 


559 


Fig.  97. — Wrist  abduction  in  action.     E,  beginning  of  wrist  extension.       F,   correct 
position  of  arm  in  pronation.      {From  McKenzie,  "Reclaiming  the  Maimed.'") 


Fig.  98. — Rotation,  flexion  and  extension  and  lateral  movements  of  the  wrist.      {From 
McKenzie,  "  Reclai?ning  the  Maimed.") 


560 


INDUSTRIAL    MEDICINE    AND    SURGERY 


of  galvanized  iron  strips,  hinged,  and  with  a  scale  pasted  on  to  a  side 
plate. 

"Most  of  the  appliances  about  to  be  described  have  protractors  at- 
tached, so  that  the  range  of  movement  can  be  watched  by  the  patient 


rG     °  :^ 


3    o    o 


^•S    fl 


S  3  2 


sr 


rH      O 


•2  « 


<D  .g 

Si 


■■■■■ 

■■■■■ 


himself,  during  the  exercise,  and  this  additional  incentive  given  him  to 
use  his  best  efforts.  The  measurement  of  abihty  to  repeat  movement 
will  be  in  terms  of  weight  raised  and  number  of  repetitions.  The  maxi- 
mum strength  of  the  grip  can  be  taken  conveniently  by  partly  inflat- 
ing the  cuff  of  a  Tycos  sphygmomanometer  and  noting  the  height  to 


TREATMENT    OF    INJURIES 


561 


which  the  mercury  is  raised  when  the  cuff  is  squeezed.  This  is  quite 
as  rehable  as  Amar's  bulb,  and  is  better  than  the  ordinary  hand 
dynamometer. 

"The  apphances  are  for  two  purposes,  stretching  and  improving 
the  strength.     All  the  stretching  movements  are  kept  within  the  vol- 


's .2 


Tj  y3 


o  o  * 


75^' 


O 


^^ 


^    03 


sr 


W.= 


untary  control  of  the  patient,  who  can  be  trusted  to  desist  before 
danger  of  lacerating  firm  adhesions  is  imminent.  The  apphances 
for  improving  the  strength  can  be  loaded  with  increasing  weights  as 
the  power  to  lift  them  returns  and  the  patient  can  be  interested  in 
watching  the  extent  of  each  movement,  as  shown  on  the  scale,  in  watch- 
ing the  rising  weight  as  it  is  hfted,  in  calculating  the  total  amount 

36 


562 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Fig.  103. — Pulley  weights  for  exercising  fingers  in  flexion  and  extension,  right 
hand  doing  exercise  1,  left  hand  with  thumb  attachment  doing  abduction.  {From 
McKenzie,  "Reclaiming  the  Maimed.") 


Fig.  104.- 


-Crumpling  up  a  newspaper  as  an  exercise  for  the  hand. 
"Reclaiming  the  Maimed.") 


(From  McKenzie, 


TREATMENT    OF    INJURIES 


563 


i 

W^ 

.  1     i 

r^ 

■^&1# 

1      t 

j.^^  :i  ^-^.,.^.  -J;    -r 

'  ^W^^^t^B^^^sL^ 

'         "^    J    Mk2 

Fig.  105. — Amputated  case  learning  control  on  the  balance  beam. 
"Reclaiming  the  Maimed.") 


{From  McKenzie, 


Fig.  106. — Amputated  case  practicing  walking  through  the  ladder  to  exercise 
the  stump  and  teach  control.  Inversion  and  eversion  treads  also  shown.  {From 
McKenzie,   "Reclaiming  the  Maim, ed.") 


564  INDUSTRIAL    MEDICINE    AND    SURGERY 

of  work  done  in  foot  pounds,  or  in  listening  to  and  counting  the  clicks 
of  the  ratchet  as  the  movement  is  made. " 

The  author  refers  the  reader  to  McKenzie's  book,  "Reclaiming 
the  Maimed"  for  a  complete  description  of  these  various  forms  of 
mechanotherapy.  Figures  97  to  107  show  the  varied  exercises  which 
can  be  obtained  by  the  McKenzie  apparatus. 

The  chief  point  about  mechanotherapy  is  that  the  patient  is  his 
own  doctor  and  after  his  interest  in  the  game  is  once  aroused,  he  can 
usually  be  depended  upon  to  exert  every  effort  to  overcome  the  lost 
function.  In  many  cases  of  ankylosed  joints  following  recent  in- 
juries, motion  can  be  restored  by  daily  persistent  exercising  over  a 
period  of  a  few  weeks.     In  contradistinction  to  this  method  consider 


Fig.  107. — A  hammer  handle  made  to  fit  a  deformed  hand.  It  is  first  surrounded 
with  dental  wax  softened  in  hot  water,  then  patient  grasps  it  as  tightly  as  possible 
making  an  impression  of  the  deformed  hand.  Wax  is  then  hardened  by  dipping  in  cold 
water.  Patient  now  has  a  handle  shaped  to  his  hand.  As  flexion  develops  in  fingers 
new  impressions  are  made.      (Allen.) 

the  great  damage  which  has  often  been  done  by  surgeons  forcibly 
breaking  up  one  of  these  ankylosed  joints.  The  tissues  are  practically 
always  lacerated  and  the  ligaments  may  be  torn  away  from  their 
attachments.  The  adhesions  which  form  during  the  healing  process 
following  this  operation  often  cause  a  worse  ankylosis.  Patience  is  the 
first  lesson  which  the  industrial  surgeon  must  learn. 

GYMNASTICS  AND  GAMES 

A  long  sojourn  in  the  hospital  develops  hospitalization  which  is 
characterized  by  sluggishness  of  mind  and  body.  The  patient's 
physical,  mental  and  moral  stamina  is  greatly  lowered  and  demands 


TREATMENT    OF    INJURIES 


565 


treatment  just  as  much  as  the  injured  part  demanded  surgical  care. 
The  neglect  of  this  state  of  hospitalization  has  resulted  in  prolonged 
disabihty  and  in  many  unjust  claims  for  compensation  on  the  part  of 
the  patient. 

Gymnastics,  special  setting-up  exercises  and  outdoor  games  have 
been  found  of  the  greatest  value  in  overcoming  the  damage  done  by  the 
enforced  idleness  of  hospital  hfe.     These  methods  have  especially  been 


Fig.  108. — An  amputated  case  learning  to  use  his  artificial  appliance  by  playing  ball. 


employed  among  the  soldiers  convalescing  from  their  war  injuries.  In 
development  battaUons  in  this  country  many  an  injured  soldier,  or  one 
disabled  by  disease,  has  been  restored  to  full  duty  by  special  exercises 
drills  and  games  carried  on  under  the  supervision  of  the  medical  officer. 
Before  the  estabhshment  of  development  battaHons,  this  same  class  of 
patients  was  discharged  from  the  army  as  unfit,  and  to-day,  constitute 
a  large  group  of  the  discharged  disabled  soldiers  drawing  compensation. 
Special  gymnastic  exercises   can  be  given  to  many  of  the  bed 


566 


INDUSTRIAL    MEDICINE    AND    SURGERY 


patients  with  very  beneficial  results.     By  gradually  increasing  these, 
they  can  leave  their  beds  with  strong  muscles  and  generally  increased 


J 


IJ    ■ 


A 


Fig.  109. — Soldier  patients  at  Walter  Reed  Hospital  cutting  short  the  time  of  con- 
valescence by  graduated  physical  exercise.      (Bryant.) 


J"" 


Fig.   110. — Same  as  Fig.  100.     Arrangements  should  be  made  for  the  physical  develop- 
ment of  all  convalescents  in  our  civil  hospitals. 

strength  instead  of  the  weakened,  emaciated  condition  which  cause  so 
many  to  faint  when  they  first  try  to  get  out  of  bed.     Graded  exercises 


TREATMENT    OF    INJURIES  567 

can  be  given  in  the  hospital  wards  to  all  the  patients  who  are  able  to 
stand  up.  This  should  be  one  of  the  functions  of  the  internes  in  our 
hospitals.  The  exercises  should  be  made  so  interesting,  and  their 
purposes  so  carefully  explained  to  the  patients  that  everyone  would 
enter  into  the  game  with  the  idea  of  getting  the  greatest  benefit  from 
it.  Every  hospital  should  be  surrounded  with  sufficient  ground  space 
where  outdoor  exercises  and  games  could  be  indulged  in  by  these 
patients  as  a  definite  part  of  their  therapeutic  care.  Instead  of  send- 
ing softened,  physically  and  mentally  dejected  patients  away  from  our 
hospitals  as  we  do  to-day,  such  methods  would  turn  out  strong,  vigor- 
ous patients  anxious  to  return  to  their  employment. 

From  the  standpoint  of  the  medical  profession  the  war  will  be  of 
great  value  if  we  learn  to  use  all  of  these  therapeutic  adjuncts  in  con- 
nection with  the  permanent  treatment  of  our  accident  cases. 

Surgeons  in  industry  have  made  great  strides  during  the  last 
decade  in  the  treatment  of  injured  employees.  They  undoubtedly 
will  be  among  the  first  to  grasp  this  line  of  treatment  which  will  give 
not  only  the  best  surgical  end-result  but  the  very  best  economic 
end-result. 


CHAPTER  XXXV 


X-RAY  IN  INDUSTRIAL  SURGERY 


Five  years  ago  very  few  industrial  dispensaries  were  equipped  with 
a  complete  a;-ray  laboratory.  At  the  present  time  this  is  recognized  as 
one  of  the  most  important  accessories  to  the  surgical  dispensary  and 
several  plants  have  installed  most  up-to-date  machines.  An  expert 
rontgenologist  on  the  surgical  staff  is  equally  important. 

When  a;-ray  facihties  are  lacking  in  the  plant  dispensary  equip- 
ment injured  employees  who,  in  the  judgment  of  the  surgeon,  actually 


Fig.   111. — X-ray  room  in  doctor's  office.    {Courtesy  of  Ford  Co.) 

need  x-ray  examinations,  are  referred  to  some  outside  hospital  or 
laboratory.  The  charges  for  such  work  average  approximately  five 
($5.00)  dollars  per  case.  Naturally  the  management  requires  and  the 
surgeon  is  desirous  to  keep  the  cost  of  the  surgical  work  at  a  minimum. 
Therefore,  he  refrains  from  sending  many  injured  employees  for  such 
examinations  unless  there  is  a  very  definite  indication.  Whereas,  if 
an  a;-ray  laboratory  was  close  at  hand  which  could  be  used  at  approxi- 

568 


X-RAY    IN    INDUSTRIAL    SURGERY  569 

mately  very  little  expense  per  case,  many  of  these  patients  would 
receive  such  an  examination  at  once. 

As  a  result  of  this  short-sighted  poHcy  the  delayed  rc-ray  examina- 
tion is  often  a  direct  cause  of  the  prolonged  clisabiHty.  Any  industry 
where  a  sufficient  number  of  accidents  occur  as  to  warrant  a  medical 
staff,  wastes  the  price  of  an  a;-ray  equipment  and  its  operation  every 
year  by  paying  excessive  prices  for  these  examinations  on  the  outside 
and  by  the  prolonged  disabihty  in  other  cases  which  would  have  been 
benefited  by  an  early  radiographic  examination. 

We  will  take  it  for  granted  that  every  emergency  surgeon  to-day 
uses  this  method  in  all  cases  where  the  need  is  obvious.  In  addition 
to  these,  other  patients  are  constantly  reporting  to  the  dispensary 
every  day  who  should  be  rc-rayed.  The  following  types  of  injuries 
require  this  form  of  examination: 

1.  Every  injured  employee  reporting  to  the  office  with  a  sprain 
should  be  x-rayed.  Routine  radiographic  examination  of  so-called 
sprains  will  reveal  approximately  10  per  cent,  of  these  are  due  to 
fractures,  especially  small  linear  fractures.  Many  of  these,  diagnosed 
at  first  as  sprains  and  treated  as  such,  fail  to  respond  to  treatment 
and  after  a  week  or  two  the  surgeon  decides  to  rc-ray  them,  thus  dis- 
covering the  fracture.  Immediate  proper  immobilization  and  rest  of 
the  part  would  have  resulted  in  prompt  recovery,  but  two  weeks 
unnecessary  time  has  been  wasted.  Some  of  these  cases  of  delayed 
diagnosis  of  fracture  fail  to  unite  and  wiring  of  the  fragments  or  bone 
transplantation  or  other  open  methods  become  necessary.  It  is  almost 
impossible  for  the  surgeon  to  square  himself  with  the  patient  when  the 
diagnosis  of  a  fracture  has  thus  been  unnecessarily  delayed.  Such 
mistakes  can  only  be  avoided  by  the  routine  rc-ray  examination  of  all 
injuries  where  the  remotest  chance  of  a  fracture  may  exist. 

2.  All  eye  injuries  due  to  foreign  bodies,  except  such  minor  con- 
ditions as  a  cinder  or  dust  not  buried  in  the  eye,  should  be  rc-rayed. 
It  frequently  happens  that  a  small  particle  of  steel  or  emery  will 
penetrate  the  eyeball  to  a  great  depth  without  leaving  any  perceptible 
wound  of  entrance.  Such  foreign  material  is  not  discovered  until  weeks 
afterward  when  it  has  done  irreparable  harm.  The  loss  of  both, 
eyes  has  followed  these  simple  injuries  whereas  an  early  a;-ray 
diagnosis  would  have  prevented  such  dire  results.  The  importance 
of  the  routine  rontgen  examination  of  eye  injuries  is  illustrated  by 
the  following  case : 

Mr.  J.  R.,  male,  34  years  old,  was  employed  in  a  tool  factory. 
His  work  necessitated  occasional  grinding  on  an  emery  wheel. 
Goggles  were  provided  but  were  not  kept  in  repair  and  the  manage- 
ment did  not  require  the  emploj^ees  to  use  them.  One  day  while 
grinding,  the  wheel  cracked  and  several  pieces  of  emery  were  forcibly 


570  INDUSTRIAL    MEDICINE    AND    SURGERY 

thrown  off.  One  of  these  struck  the  employee  at  the  outer  canthus 
of  the  left  eye  but  he  did  not  think  any  portion  entered  the  eyeball. 
One  of  his  fellow  employees  examined  the  eye  but  could  find  no  sign 
of  injury.  Two  days  later,  another  employee  playfully  threw  a  wad 
of  waste,  used  for  wiping  a  machine,  at  J.  R.  and  it  struck  him  in 
the  left  eye.  Two  hours  later  this  eye  became  inflamed  and  very 
painful.  He  reported  to  the  boss  and  blamed  his  trouble  on  the  waste 
which  struck  him  in  the  eye.  He  was  immediately  referred  to  an 
excellent  eye  specialist  who  cared  for  all  eye  cases  for  the  insurance 
company  under  which  this  concern  was  insured.  Examination  by  the 
eye  specialist  failed  to  reveal  any  foreign  particles  as  a  cause  of  the 
conjunctivitis  and  iritis.  He  explained  to  J.  R.  that  the  badly  in- 
flamed condition  of  the  eye  was  due  either  to  diseased  tonsils  or  an 
infected  tooth.  In  order  to  satisfy  the  patient,  he  called  another  eye 
specialist,  of  excellent  repute,  in  consultation  and  the  latter  agreed 
with  this  diagnosis.  J.  R.,  on  the  advice  of  these  doctors,  imme- 
diately had  his  teeth  rc-rayed,  followed  by  the  removal  of  two  infected 
teeth.  The  eye  condition  persisted  and  the  patient  finally  consulted 
his  family  physician.  This  doctor  had  attended  J.  R.  in  two  attacks 
of  appendicitis  and  so  he  advised  him  to  get  rid  of  this  focus  of  infection. 
J.  R.  was  referred  to  the  author  who  operated  on  him  for  appendicitis, 
removing  a  chronically  inflamed  appendix,  and  ten  days  later  the  dis- 
eased tonsils  were  removed.  The  eye  remained  inflamed  but  during 
this  period  in  the  hospital,  the  pain  was  greatly  relieved. 

The  insurance  company  was  anxious  to  secure  a  settlement  of 
this  case  and  on  the  advice  of  their  eye  specialist,  took  the  position 
that  the  slight  injury  complained  of  was  not  responsible  in  any  way  for 
the  condition.  The  other  eye  specialist  and  the  author  contended 
that  while  the  foci  of  infection  in  the  patient's  body  might  have  been 
the  source  of  infection,  yet  the  injury  was  undoubtedly  the  pre- 
disposing factor.  As  the  case  was  of  intense  interest  from  the  medico- 
legal standpoint,  I  requested  J.  R.  to  report  to  the  night  chnic  on 
Industrial  Medicine  and  Surgery  at  Rush  Medical  College  in  order 
to  demonstrate  the  condition  to  the  students.  In  the  midst  of  this 
demonstration,  one  of  the  students  reminded  the  author  that  we  had 
neglected  x-raying  the  eye,  one  of  the  very  things  we  had  been  teaching 
these  students  to  do  in  every  case  of  eye  injury.  The  eye  was  im- 
mediately radiographed  and  to  our  great  chagrin,  a  small  foreign  body 
was  located  deep  in  the  eyeball. 

This  settled  all  legal  controversy  in  the  case  at  once.  Two  opera- 
tions performed  by  the  second  eye  speciahst  were  required  before 
this  small  body  was  successfully  removed.  It  had  undoubtedly 
penetrated  the  eye  at  the  time  the  emery  wheel  broke. 

Every  physician  and  certainly  every  eye  specialist  as  well  as  these 


X-RAY    IN    INDUSTRIAL    SURGERY  571 

medical  students  should  benefit  by  such  lessons  and  routine  x-ray 
examinations  of  eye  injuries  should  become  a  fixture  in  the  practice 
of  medicine. 

3.  All  deep  scalp  wounds  should  be  immediately  a:-rayed.  Frac- 
tured skulls  will  thus  often  be  revealed  when  exploration  of  the  skull 
by  the  surgeon  may  fail  to  show  the  condition. 

4.  Immediate  rontgen  examination  of  employees  who  have  passed 
through  rather  serious  accidents  without  receiving  any  apparently 
major  injury  is  very  important  from  a  medicolegal  standpoint.  Such 
patients,  when  they  reach  home,  may  be  influenced  to  magnify  their 
minor  injuries,  especially  if  the  nature  of  the  accident  warrants  it. 
These  patients  will  remain  away  from  the  surgeon  and  several  weeks 
later  may  bring  claim  for  broken  bones,  dislocations,  etc.  The 
following  case  illustrates  the  importance  of  this  procedure: 

Mr.  J.,  58  years  old,  a  salesman,  was  called  to  a  certain  industry 
to  consult  with  one  of  the  managers  regarding  some  special  equipment 
which  the  concern  desired  to  procure.  In  walking  through  the  aisle 
in  one  of  the  departments,  he  stumbled  over  a  small  box  which  had  been 
carelessly  left  there,  and  fell  forcibly  to  the  floor.  He  was  taken  to  the 
doctor's  office  and  thoroughly  examined  but  no  sign  of  injury  was  found. 
He  complained  bitterly  of  pain,  however,  and  stated  openly  that  the 
concern  would  have  to  pay  him  for  damages.  He  exaggerated  his 
symptoms  and  made  so  much  fuss  that  the  assistant  surgeon  who  was 
in  charge  at  the  time,  told  him  he  was  a  fakir. 

The  management  called  a  taxicab  and  sent  Mr,  J.  to  his  home. 
Two  weeks  later  his  family  physician  called  the  author  and  stated 
that  Mr.  J.  had  sustained  an  injury  of  his  right  hip-joint  at  the  time 
he  fell  and  that  motion  in  this  joint  was  limited  by  an  excessive  callous 
formation.  He  had  proven  this  condition  by  an  x-jay  examination. 
On  inquiry,  I  found  that  Mr.  J.  was  up  and  around  although  he  suf- 
fered considerable  pain  in  his  hip.  I  suggested  that  the  physician 
and  his  patient  meet  me  at  the  hospital  where  a  thorough  examination 
could  be  made  and  if  the  concern  was  responsible,  arrangements  would 
be  made  for  a  settlement.  This  plan  was  agreed  to.  Examination 
of  the  x-ray  plate  showed  a  large  amount  of  bony  formation  about  the 
hip-joint.  A  chronic  arthritis  deformans  was  immediately  suspected 
but,  without  mentioning  this  fact,  I  asked  permission  to  have  a  new 
x-ray  picture  made  at  the  hospital.  This  was  done  but  instead  of  hmit- 
ing  the  examination  to  the  right  hip,  every  joint  in  the  patient's  body 
was  radiographed.  Similar  bony  deposits  were  found  about  the  left 
hip-joint,  about  the  knee-joints  and  about  one  of  the  shoulder-joints. 
The  rontgenologist  reported  that  there  was  no  sign  of  fracture  about 
the  right  hip-joint  but  that  this  patient  was  suffering  from  a  chronic 
arthritis  deformans.     Mr,   J.'s   family  physician  was  convinced  and 


572 


INDUSTRIAL    MEDICINE    AND    SURGERY 


together  we  were  able  to  persuade  Mr.  J.  that  his  trouble  had  existed 
long  before  this  fall.     The  claim  for  settlement  was  dropped. 

An  immediate  a;-ray  examination  at  the  time  of  the  injury  would 
have  revealed  the  true  condition  and  would  have  prevented  this 
controversy  which  might  have  resulted  in  a  very  serious  financial  loss 
to  this  concern. 

The  x-ray  is   of  great  assistance  in  other  types  of  emergency 


t 
1 

1 
I 

■„ 

1 

!     i 

1 

t 

Fig.    112. — A  portable  x-ray  machine  especially  serviceal)le  in  accident  surgery. 

surgery.  Foreign  bodies  which  have  penetrated  soft  tissues  can  be 
immediately  located  and  quickly  removed  by  its  use.  Pieces  of 
steel,  broken  needles  and  other  such  material,  which  often  require  an 
operation  of  one  or  two  hours  in  order  to  remove,  can  be  deftly  taken 
out,  the  operation  being  performed  in  a  dark  room  under  the  guidance 
of  the  fluoroscope.  By  looking  through  the  fluoroscope  the  needle  or 
piece  of  steel  is  located.     An  incision  is  made  immediately  over  the 


X-RAY    IN    INDUSTRIAL    SURGERY  573 

part,  and  a  pointed  artery  forceps  is  introduced  and  guided  by  the  eye 
until  the  foreign  material  is  grasped.  If  the  material  cannot  be 
immediately  withdrawn  the  fluoroscope  is  put  aside,  the  room  lighted 
and  with  the  forceps  as  a  guide,  the  foreign  body  can  be  carefully 
dissected  out. 

War  surgery  has  developed  several  different  types  of  localizers 
to  use  in  connection  with  the  a;-ray  and  these  must  be  adapted  to 
our  industrial  surgery.  One  of  these  apphances,  the  Granger  localizer, 
is  clearly  described  by  the  inventor  in  the  4pril,  1918,  issue  of  the 
American  Journal  of  Electrotherapeutics  and  Radiology. 

In  the  really  up-to-date  doctor's  office  in  industry,  every  effort  is 
made  to  thoroughly  diagnose  every  case  coming  before  the  doctors. 
In  order  to  do  this,  the  a;-ray  is  often  a  necessary  adjunct  to  our 
diagnostic  methods.  Cases  of  pulmonary  tuberculosis  may  be  con- 
firmed by  this  method  whereas  an  early  diagnosis  might  be  delayed 
until  cHnical  signs  were  m.anifested.  Gastro-intestinal  diagnosis  or 
diagnosis  of  conditions  in  the  urinary  tract  can  be  made  in  the  plant 
dispensary  by  the  rontgen  rays. 

Fig.  112  illustrates  the  U.  S.  Army  bedside  a:-ray  unit.  It  was 
designed  to  permit  x-ray  examination  in  the  wards  thus  limiting  the 
disturbance  of  the  patient.  This  machine  is  adaptable  to  almost  all 
the  needs  of  an  industrial  dispensary  and  will  reduce  the  cost  of  equip- 
ping a  laboratory  to  almost  one-half.  It  will  also  be  of  the  greatest 
value  in  the  hospital  wards  where  the  serious  accident  cases  are  under 
treatment.  This  is  one  of  the  advances  in  war  surgery  which  can  well 
be  copied  by  industrial  surgery. 

No  surgeon  in  industry  to-day  can  afford  to  neglect  rc-ray  examina- 
tions. To  many  managements  the  installation  of  this  expensive 
equipment  seems  a  luxury  but  it  is  the  duty  of  every  surgeon  to 
demonstrate  its  economic  value  both  to  the  employee  and  employer. 


CHAPTER  XXXVI 
HAND  INFECTIONS 

Infections  following  injuries  have  been  responsible  for  a  very  large 
percentage  of  the  human  wastage  in  industry.  Their  prevention 
therefore  is  one  of  the  paramount  duties  of  the  surgeon. 

In  a  few  concerns,  from  which  figures  have  been  obtained  before 
industrial  surgery  became  a  definite  part  of  their  organization,  as 
high  as  20  to  30  per  cent,  of  all  injury  cases  became  infected.  With 
the  installation  of  preventive  surgical  methods,  however,  this  complica- 
tion has  been  markedly  reduced. 

It  is  difficult  to  obtain  comparative  figures  from  the  different 
industrial  cHnics  due  to  a  divergence  of  opinion  as  to  what  constitutes 
an  infected  wound,  and  to  the  fact  that  many  surgeons  base  their 
statistics  only  upon  those  cases  which  observe  the  rules  concerning 
prevention. 

A  wound  which  shows  the  least  evidence  of  invasion  by  pyogenic 
organisms  should  be  classified  as  an  infected  wound.  Some  of  these 
will  show  only  redness  and  a  slight  swelling  for  a  day  or  two  and 
will  then  recover  without  definite  pus  formation;  while  others  may 
show  no  local  sign  of  infection  but  a  slight  or  marked  lymphangitis 
will  develop  only  to  disappear  in  twenty-four  to  forty-eight  hours 
without  any  further  comphcations.  I  include  such  cases  as  these  in 
my  statistics  as  well  as  the  wounds  exuding  pus. 

One  surgeon  reports  that  he  has  one  infected  case  in  every  1000, 
and  another  states  that  one  out  of  every  991  injuries  becomes  infected. 
Both  of  these  surgeons  consider  only  cases  showing  definite  pus  as 
infected,  and  both  agree  that  they  have  many  other  infected  cases 
to  treat  but  these  occur  in  employees  who  failed  to  report  to  the  doctor 
at  once,  or  who  removed  their  dressings  and  otherwise  neglected 
treatment. 

In  the  author's  experience  only  0.4  per  cent,  of  the  26,616  more  re- 
cent accident  cases  became  infected  where  the  employees  observed  all 
rules  about  reporting  to  the  doctor  at  once  and  continuing  constantly 
under  treatment  until  the  wound  was  healed  (Table  18). 

Each  year  has  seen  a  gradual  reduction  in  the  number  of  infected 
cases,  but  we  still  have  a  number  of  such  to  treat.  As  explained  else- 
where this  is  due  to  the  fact  that  employees  still  fail  to  report  to  the 
doctor  at  once;  still  refuse  to  consider  very  slight  wounds  worthy  of 
any  attention,  just  as  you  and  I  persist  in  neglecting  the  little  scratches 

574 


HAND    INFECTIONS 


575 


and  abrasions  we  receive  almost  daily;  and  still  neglect  to  continue 
under  treatment  or  persist  in  tampering  with  their  dressings.  Many 
of  these  employees  report  to  the  doctor  with  the  wound  already 
infected  (Fig.  113). 

The  following  table  shows  the  percentage  of  all  infections  as  com- 
pared with  the  total  number  of  accidents  each  year,  for  a  period  of  five 
years.  It  illustrates  three  points  very 
well,  namely,  that  the  number  of 
infected  cases  made  a  very  decided 
drop  upon  the  introduction  of  more 
active  preventive  measures;  that  the 
percentage  of  infection  cases  is  de- 
creasing year  by  year  (about  80  per 
cent,  of  these  occur  among  new  em- 
ployees); and  that  the  employees  are 
reporting  more  and  more  to  the  doctor 
as  shown  by  the  increased  number  of 
accident  cases. 

In  the  cases  for  the  last  four  years 
shown  in  this  table  only  49  became 
infected  after  using  iodin  at  once  and 
reporting  to  the  doctor  at  once;  80 
became  infected  after  reporting  to  the 
doctor  at  once  but  failed  to  use  iodin 
in  the  department.  None  of  these 
were  sufficiently  infected,  however,  as 
to  require  an  incision  nor  to  remain 
away  from  work  on  account  of  the  con- 
dition. The  remaining  2436  infected 
cases  failed  to  observe  these  rules  con- 
cerning the  use  of  iodin  at  once  and 
the  reporting  to  the  doctor  at  once; 
71  per  cent,  of  these  required  incision 
of  the  infected  part;  and  all  employees 
in  this  group  lost  a  total  of  9744  days 
from  work  or  an  average  of  four  days 
per  man.  The  economic  waste  to  in- 
dustry is  surely  quite  evident. 

Infections  as  a  rule  follow  minor  accidents,  and  these  are  by  far 
the  most  diflEicult  type  to  prevent.  Infections  following  minor  in- 
juries to  fingers  and  hands  make  up  at  least  95  per  cent,  of  the  infected 
cases  coming  under  treatment  in  the  modern  industrial  clinic.  There- 
fore it  is  very  essential  for  the  surgeon  in  industry  to  master  all  de- 
tails concerning  the  prevention  and  treatment  of  hand  infections. 


Fig.  113. — Cellulitis  of  forearm 
from  a  neglected  slight  abrasion  of 
the  elbow.  Injured  Oct.  3d,  re- 
ported for  treatment  Oct.  10th. 
Immediate  treatment  would  have 
prevented  the  infection  and  no  dis- 
ability. This  delayed  treatment 
caused  two  months  lost  time  from 
work  and  cost  the  employer  three 
hundred  and  forty  dollars. 


576 


INDUSTRIAL    MEDICINE    AND    SURGERY 

Table  18 


1912 

1913 

1914 

1915 

1916 

1.  Total  number  of  accidents 

2.  Total  number  of  infections 

(95%  hands) 

2693 

772 
(28.6%) 

No 
record 

No 
record 

No 
record 

4970 
710 

14% 

18 

28 
668 

5971 
655 

10% 

16 

28 
611 

7760 
586 

7.5% 

5 

12 
569 

7925 
610 

7.6% 

3.  Infected  cases  where  iodin  was  used 
in  department  and  then  reported  at 
once  to  doctor 

10 

4.  Infected  cases  where  iodin  was  not 
used  in  department  but  reported  at 
once                   

12 

5.   Infected   cases  where  these    rules 
were  not  observed 

588 

The  part  played  by  hand  infections  in  the  economy  of  the  indus- 
trial worid  is  shown  by  the  following  statistics  and  statements  from 
various  industries  and  accident  insurance  companies: 

1.  From  4971  accidents,  11  per  cent,  became  infected.  Total  disa- 
bility from  these  accidents  was  13,000  days,  and  20  per  cent,  of  this 
was  due  to  the  infections. 

2.  From  one  of  the  stockyard  plants: 

Seventy-five  per  cent,  of  disability  from  hand  injuries  is  the  result  of 
infections;  25  per  cent,  of  disability  from  hand  infections  is  due  to  other 
causes,  such  as  broken  bones,  etc.;  90  per  cent,  of  these  hand  infections 
report  late,  after  the  infection  has  developed;  75  per  cent,  of  their  hand 
deformities  are  the  result  of  infections. 

3.  Figures  obtained  from  the  claim  departments  of  five  of  our 
largest  accident  insurance  companies: 

(a)  Fifteen  per  cent,  of  the  total  disability  is  due  to  hand  injuries. 
In  20  per  cent,  of  these  hand  injuries,  the  disabihty  is  due  to  infections. 

(b)  Seven  per  cent,  to  9  per  cent,  of  the  total  disability  from  all 
accidents  is  due  to  hand  infections. 

(c)  From  1000  consecutive  cases,  5.7  per  cent,  of  the  total  disa- 
bility was  due  to  hand  infections  (chiefly  business  men  insured). 

(d)  From  15  to  20  per  cent,  of  the  total  disabihty  is  due  to  hand 
infections.  It  depends  on  the  type  of  work  done  by  insured.  When 
engaged  in  heavy  work,  where  the  injuries  are  usually  serious,  the  in- 
fections are  less,  but  if  engaged  in  hght  work,  where  minor  accidents 
are  the  rule,  the  infections  are  greatly  increased. 

(e)  Of  all  hand  accidents,  it  is  estimated  that  65  per  cent,  requiring 
disability  are  the  result  of  minor  injuries  which  have  become  infected; 
35  per  cent,  requiring  disability  are  due  to  other  injuries,  as  broken 
fingers,  lacerations,  crushing  injuries,  etc. 

In  talking  with  a  number  of  company  surgeons  and  managers  of 


HAND    INFECTIONS  577 

claim  departments,  I  find  that  no  definite  statistics  are  available  on 
this  subject.     They  all  agree,  however,  that: 

1.  Hand  infections  cause  a  high  percentage  of  their  disability. 

2.  Over  50  per  cent,  of  their  hand  deformities  are  the  result  of 
infected  injuries. 

3.  A  great  many  amputations  result  from  neglected,  infected 
fingers  (Fig.  114). 

4.  Hand  infections  are  usually  the  result  of  minor  injuries,  such 
as  pin  pricks,  nail  wounds,  splinters,  scratches,  small  cuts,  cracked 
hands,  blisters,  contusions,  and  abrasions.  Such  minor  cases,  as  a 
rule,  do  not  report  to  the  doctor  until  the  infection  has  developed. 


Fig.  114. — Ankylosed  middle  finger  following  neglected  hand  infection.     This  finger 
was  later  amputated  in  order  to  give  a  better  functional  result. 

5.  Severe  hand  injuries,  such  as  extensive  lacerations,  or  severe 
crushing  injuries,  seldom  become  infected.  The  nature  of  these  injur- 
ies is  such  that  the  patients  are  forced  to  consult  a  doctor  at  once. 

6.  That  early  treatment  of  all  accidents,  no  matter  how  slight, 
would  reduce  infections  to  a  marked  degree. 

PREVENTION 

Prevention  of  infections  is  one  of  the  most  fertile  fields  of  endeavor 
open  to  the  company  surgeon.  It  is  the  "Safety  First"  movement 
for  the  injured.  A  careful  study  of  the  etiology  of  every  infection 
will  show  that  the  majority  are  due  to  preventable  minor  accidents, 
and  by  a  removal  of  these  causes  a  great  reduction  in  infections  will 
ensue.  As  an  example,  the  lining  of  bins  which  had  become  loosened 
was  the  frequent  cause  of  injuries  which  became  infected.  In  every 
case,  a  notice  was  sent  to  the  manager,  pointing  out  the  preventable 

37 


578  INDUSTRIAL    MEDICINE    AND    SURGERY 

nature  of  this  accident,  and  in  one  year  the  injuries  from  this  source 
were  reduced  from  75  to  10.     The  same  procedure  was  followed  in  the 
case  of  broken  baskets,  exposed  ends  of  wire,  nails  on  the  floor,  pins  in 
packages,  etc.,  all  resulting  in  a  decrease  in  minor  accidents  and,  there- 
fore, in  infections. 

Tincture  of  iodin  is  the  greatest  protection  against  infection  that 
can  be  used.  Every  industry  should  supply  each  department  with  a 
bottle  of  tincture  of  iodin  and  another  bottle  containing  applicators, 
and  should  instruct  each  employee  to  paint  every  wound,  no  matter 
how  slight,  with  the  tincture  of  iodin  at  once,  even  before  reporting  to 
the  doctor.  The  importance  of  its  use  should  be  pointed  out  to  the 
department  foremen  again  and  again,  in  order  that  they  may  instruct 
each  new  employee  as  to  its  value.     (See  Fig.  75.) 

The  value  of  tincture  of  iodin  as  an  antiseptic  par  excellence  has 
been  pointed  out  in  the  chapter  on  First  Aid. 

The  importance  of  early  reporting  to  the  doctor  for  a  dressing  is 
not  only  demonstrated  by  the  figures  in  Table  18,  but  by  the  fact  that 
major  injuries,  which  force  the  employee  to  report  at  once,  seldom 
become  infected. 

Dr.  Frederick  C,  Warnshuis  declares  that  immediate  reporting  and 
proper  treatment  will  reduce  infection  to  less  than  1  per  cent. 

Dr.  Corwin  of  the  Colorado  Fuel  and  Iron  Company  states  that  if 
the  injured  employees  will  see  the  doctor  at  once  and  if  the  wound  is  not 
handled,  washed  or  dressed  before  seeing  the  doctor,  99  times  out  of  a 
hundred  it  will  not  become  infected. 

The  following  excerpt  of  a  report  made  by  a  safety  engineer  of  a 
large  industry  is  very  interesting  especially  as  he  feels  that  the  immedi- 
ate reporting  to  the  doctor  is  of  more  value  than  the  use  of  iodin.  By 
checking  up  on  these  cases,  however,  it  was  found  that  many  had  stated 
that  iodin  was  used  in  the  department,  but  failed  to  indicate  that  this 
was  sometime  after  the  accident.     This  engineer  says: 

''The  monthly  accident  report  shows  the  distribution  of  infections 
according  to  cause  and  demonstrates  that  practically  all  infections 
result  from  slight  injuries,  such  as,  pin  pricks,  nail  wounds,  slivers, 
abrasions,  etc.,  the  total  infections  for  the  month  being  sixty-six.  The 
figures  show  that  only  4  cases  out  of  the  66  resulted  from  injuries  that 
were  reported  immediately  to  the  hospital,  which  proves  the  efficiency 
of  the  hospital  treatment.  The  balance  were  all  reported  anywhere 
from  a  few  days  to,  in  some  cases,  weeks  later.  Out  of  the  66  infec- 
tions it  was  necessary  to  open  40. 

''This  report  also  shows  that  in  31  out  of  the  66  cases,  iodin  was  used 
in  the  department,  which  proved  that  the  use  of  iodin  alone  is  not 
sufficient  to  prevent  infections. 

"The  dressing  report  shows  that  the  average  number  of  dressings  per 


HAND    INFECTIONS  579 

person  for  infections  was  6.35,  against  2.54  for  uninfected  cases;  or, 
in  other  words,  the  patient  loses  about  two  and  one-half  times  as 
much  time  in  reporting  an  infected  case  as  an  uninfected  case. 

"The  last  classification  probably  is  the  most  interesting,  as  it  shows 
the  loss  of  time  cases.  Nineteen  of  the  66  infected  cases  caused  a  loss 
of  time  of  a  quarter  of  a  day  or  more.  The  total  loss  of  time  for  these 
19  cases  was  202)-^  days,  or  an  average  of  10.6  days  per  case;  and  the 
time  lost  over  a  quarter  of  a  day,  due  to  infections,  amounts  to  2.3  per 
cent,  of  the  total  time  lost  from  all  loss  of  time  accidents. 

"Since  it  has  been  shown  that  the  infections  result  from  minor  in- 
juries which  would  not  have  developed  into  infections  if  they  had  been 


Fig.  115. — Cellulitis  of  upper  arm  following  a  small  scratch  on  the  wrist  from 
wall-paper.  This  employee  had  three  disabling  infections  in  the  course  of  three  months. 
His  teeth  were  badly  infected  and  on  curing  this  trouble  his  tendency  to  "blood-poison- 
ing" ceased. 

reported  immediately  and  would,  therefore,  only  have  required  on  the 
average  23^^  dressings  per  case,  it  is  fair  to  assume  that  the  average 
time  lost  per  case  should  not  have  exceeded  }^'2  hour.  So,  in  the 
time  lost  by  one  of  the  above  19  cases,  or  10.6  days,  about  180  un- 
infected cases  might  have  reported. 

"From  these  figures  it  would  appear  that  the  immediate  reporting  of 
all  minor  injuries  will  cut  down  the  infections,  and  even  though  there 
will  be  an  increase  in  the  number  of  reported  cases,  the  total  time  lost, 
and  consequently  the  cost  of  the  accidents,  should  decrease." 

Another  form  of  prevention  is  the  removal  of  all  predisposing 
causes  for  infection  in  the  employees  themselves.  The  generally 
run  down,  anemic,  undernourished  individual,  or  those  suffering  from 
chronic  diseases,  are  more  prone  to  injuries  and  injury  infections. 
Thus,  the  discovery  of  the  diseased  employee  by  a  periodical  medical 


580  INDUSTRIAL   MEDICINE    AND    SURGERY 

examination  of  all  employees  is  a  valuable  adjunct  to  any  system  of 
prevention.  By  proper  advice  many  of  these  diseased  conditions  can 
be  overcome;  a  change  of  work  may  be  indicated  in  other  cases,  and 
the  regulation  of  the  employee's  mode  of  living,  both  at  work  and  at 
home,  and  ^s  regards  outdoor  exercise,  will  correct  a  great  many  of  the 
anemic,  undernourished,  and  run  down  conditions.  In  girls,  we  fre- 
quently see  recurring  infections  in  the  same  individuals.  A  study  of 
the  case  will  reveal  a  marked  anemia,  the  correction  of  which  overcomes 
her  tendency  to  infections  (Fig.  115). 

Tonsillitis,  one  of  the  chief  causes  of  sick  disability  among  em- 
ployees, also  plays  a  marked  role  in  the  cause  of  infections.  In  the 
winter  months,  when  tonsillitis  is  the  most  prevalent,  our  infections 
are  correspondingly  high.  The  coincidence  of  tonsillitis  and  finger 
and  hand  infections  was  noted  so  often  that  I  made  a  careful  bacterio- 
logical study  of  a  series  of  these  cases,  and,  as  a  rule,  the  same  germ 
was  found  to  be  the  cause  of  both. 

The  following  table  shows  this  relationship.  Note  the  increase 
in  hand  infections  with  the  increase  in  tonsillitis.  (These  figures  are 
taken  from  the  same  working  force,  with  the  same  working  conditions 
prevailing.) 

Table  19 

January  and  February,  1913.     Total  number  cases  of  tonsillitis 327 

January  and  February,  1913.     Total  number  cases  of  hand 

infections 83 

Total  days  disability  from  hand  infections 63 

Number  of  hand  infections  having  tonsillitis  at  time  or  just 

before  infection  developed 15,  or  18  per  cent. 

In  1914,  we  had  in  Chicago  a  serious  epidemic  of  tonsillitis,  of  the  streptococcic 
type. 

January  and  February,  1914.     Total  number  cases  of  tonsillitis 603 

January  and  February,  1914.     Total  number  cases  of  hand 

infections 117 

Total  days  of  disability  from  hand  infections 208 

Number  of  hand  infections  having  tonsillitis  at  time  or  just 

before  infection  developed 32,  or  27.9  per  cent. 

The  greatly  increased  disability  in  1914  was  due  to  24  very  serious 
cases  with  marked  lymphangitis  and  tenosynovitis,  all  of  whom  had 
tonsillitis.  Twelve  of  these  were  due  to  a  hemolytic  streptococcus, 
and  the  same  organism  was  found  in  the  patient's  tonsils.  Twelve 
others  had  a  marked  lymphangitis,  and  while  the  organism  was  not 
ascertained,  yet  these  were  undoubtedly  streptococcic  infections  and 
closely  related  to  the  tonsillitis. 

The  removal  of  the  tonsils  when  diseased,  therefore,  would  not 
only  stop  the  sick  disability  and  the  spread  of  the  disease  throughout, 


HAND    INFECTIONS  581 

a  department  as  an  epidemic,  but  would  be  a  great  preventive  measure 
against  infections. 

A  further  and  very  important  factor  in  the  prevention  of  infections 
is  a  suitable  emergency  office,  where  the  most  aseptic  surgical  treatment 
can  be  rendered. 

Thus  the  most  valuable  preventive  measures  to  avoid  infections  are : 

1.  The  use  of  tincture  of  iodin  at  once  as  a  prophylactic  measure, 

2.  The  sending  of  every  injured  employee  to  the  doctor  for  im- 
mediate dressing. 

3.  Removal  of  external  causes  for  accidents — found  in  the  working 
place. 

4.  Removal  of  predisposing  causes  for  infections — found  in  the 
employees. 

ACTIVE  TREATMENT 

When  an  infection  has  once  developed,  the  best  medical  treatment 
is  at  times  the  most  expensive,  but  in  the  long  run,  it  is  the  most 
economical.  Too  often,  a  doctor  hopes  to  save  his  patient  loss  of  time, 
or,  if  he  is  a  company  surgeon,  he  hopes  to  treat  the  case  and  still  keep 
him  at  work:  thus  he  adopts  what  at  first  seems  the  most  economic 
line  of  treatment,  but,  by  so  doing,  frequently  temporizes  with  the 
infection.  The  death-rate  from  hand  infections  among  the  medical 
profession  is  notoriously  high.  I  believe  this  is  due  not  so  much  to 
the  peculiar  nature  of  the  doctor's  work,  wherein  he  is  brought  into 
close  contact  with  diseased  conditions,  as  to  the  fact  that  most  doctors 
temporize  with  an  infection  which  they  have  contracted,  rather  than 
adopt  active  treatment  at  once. 

From  a  careful  study  of  1600  cases  of  finger  and  hand  infections 
and  their  compHcations  I  am  convinced  that  a  radical  form  of  treatment 
of  all  hand  infections  is  the  best  and  cheapest  plan  that  can  be  adopted: 

The  initial  cost  of  such  treatment  will  exceed  a  temporizing  effort, 
such  as  opening  an  infection  in  the  office  and  allowing  the  patient 
to  go  about  his  duties,  but  the  length  of  treatment  and  the  complica- 
tions developing  from  the  latter  method  will  far  exceed  that  which 
follows  the  treatment  of  all  infections  as  serious  from  their  incep- 
tion. In  dealing  with  this  subject  from  an  economic  viewpoint,  it  is 
not  the  actual  cost  of  medical  services  which  is  referred  to,  but  the 
actual  economy  to  the  patient  and  to  the  concern  for  which  he  works. 
The  most  perfect  line  of  treatment  must  give: 

1.  The  shortest  disabifity,  with  a  minimum  amount  of  suffering, 
and  the  fewest  hardships  to  those  dependent  upon  the  patient; 

2.  It  must  prevent  permanent  deformities,  such  as  loss  of  function, 
or  loss  of  fingers; 

3.  It  must  reduce  the  death-rate  to  a  minimum. 


582 


INDUSTRIAL    MEDICINE    AND    SURGERY 


These  1600  cases  of  hand  infections  were  chiefly  the  result  of 
minor  accidents,  such  as  the  following,  named  in  their  order  of  fre- 
quency: pin  pricks,  spHnters,  abrasions  from  baskets,  boxes,  bins,  etc.; 
lacerations  from  knives,  scissors,  and  other  sharp  utensils;  bruises 
and  contusions,  nail  wounds,  scratches  from  tin  and  wire.  The 
greater  portion  of  these  infections  were  very  slight  causing  no  loss 
of  time  from  work,  and  requiring  from  3  to  10  dressings.  Nevertheless, 
there  was  a  certain  disability  connected  with  them,  as  an  employee 
with  a  bandaged  finger  or  hand  has  less  working  capacity  than  an 


Fig.  116. — Slight  infections,  especially  lymphangitis,  are  treated  as  serious  from 
their  inception.  Rest,  immobilization  of  the  part  and  continuous  applications  of  heat 
usually  abort  these  in  twenty-four  hours.      (Men's  rest  room,  doctor's  office.) 

unhampered  employee.  Therefore,  reduction  in  the  total  number  of 
infections  means  a  marked  saving  in  this  form  of  disability.  It  has 
been  further  reduced  by  careful  attention  to  the  simplest,  yet  adequate, 
dressing  which  can  be  applied.  A  certain  number  of  the  above 
infections  became  serious,  requiring  considerable  treatment  either 
at  home  or  at  the  hospital,  and  caused  an  actual  loss  of  time  from  work. 
Thus,  the  1600  cases  may  be  classified  as  follows: 

(a)  Mild,  or  causing  no  loss  of  time,  1189,  or  74  per  cent. 

(6)  Serious,  or  causing  loss  of  time,  411,  or  26  per  cent. 

In  order  to  arrive  at  the  best  and  most  economic  treatment  of 
these  hand  infections,  it  is  necessary  for  us  to  study  the  411  cases 


HAND    INFECTIONS  583 

from   the  above  table  which  were  serious  enough  to  require  actual 
disabihty. 

One  of  two  plans  of  treatment  was  adopted  in  every  case  of  hand 
infection;  namely,  ambulatory  treatment,  or  hospital  treatment.     The 


Fig.  117. — Lymphangitis  of  the  arm  from  an  infected  abrasion  on  back  of  hand. 
Thirty-six  hours  in  the  hospital  with  continuous  hot  dressings  relieved  this  condition 
without  surgical  interference. 

ambulatory  care  consisted  in  opening  the  infected  part  at  the  doctor's 
office  and  allowing  the  patient  to  go  home,  reporting  to  the  office  for 


Fig.  118. — Thenar  space  abscess  from  a  neglected  knife  wound  of  thumb.  Through 
and  through  drainage  under  a  general  anesthetic  and  hospital  treatment  for  three 
days  gave  a  prompt  recovery  without  deformity. 

subsequent  dressings.  Frequently  these  infections  were  incised  with 
the  use  of  a  local  anesthetic,  but  a  general  anesthetic  was  never  admin- 
istered in  the  doctor's  office.     When  necessary,  instructions  were  given 


584 


INDUSTRIAL    MEDICINE    AND    SURGERY 


to  the  patient  as  to  the  use  of  hot  dressings  at  home,  and  a  nurse  would 
call  to  see  that  these  instructions  were  carried  out.  Naturally  these 
infections  were  not  as  serious  as  those  given  hospital  treatment, 
but  in  spite  of  this  fact  their  average  disabiHty  was  greater.  The  ab- 
solute rest  obtained  by  hospital  treatment  would  cause  more  rapid 
recovery  of  these  cases,  but  the  idea  of  going  to  a  hospital  for  a  small, 
minor  infection  does  not  appeal  to  most  patients. 

When  a  hand  infection  showed  signs  of  becoming  at  all  serious,  or 
threatened  complications  were  apparent,  we  insisted  upon  hospital 


Fig.  119. — Tenosynovitis  of  middle  finger,  with  middle  palmar  abscess,  result  of 
cutting  finger  on  steel  tag.  The  patient  was  given  ambulatory  treatment  after  an 
effort  was  made  to  drain  the  abscess  through  a  small  incision  on  the  flexor  surface  of  the 
finger.  Proper  early  drainage  of  the  synovial  sheath  of  the  finger  would  have  prevented 
this  serious  condition. 

treatment.  Here  the  infection  could  be  opened  under  a  general 
anesthetic  of  nitrous  oxid  gas,  and  the  patient  kept  absolutely  quiet 
in  bed,  with  continuous  hot,  moist  dressings  applied  until  the  acuteness 
of  the  condition  had  subsided.  Likewise,  many  cases  of  threatened 
serious  infection  could  be  aborted  and  the  necessity  of  opening  these 
overcome  by  sending  the  patient  to  the  hospital,  giving  him  absolute 
rest  in  bed,  preventing  the  movement  of  the  infected  part,  and  applying 
continuous  hot  packs  for  twenty-four  or  forty-eight  hours  (Fig.  117). 

The  use  of  a  general  gas  anesthetic  is  one  of  the  most  valuable 
features  of  hospital  treatment  when  it  is  necessary  to  operate  on  these 


HAND    INFECTIONS 


585 


hands.  The  work  of  the  operator  is  much  more  thorough,  and  in- 
cisions into  the  infected  part  are  larger  and  better  drainage  is  estab- 
lished. Wide-open,  radical  treatment  of  these  infections  means  a  much 
more  rapid  recovery;  therefore,  the  advantage  of  this  procedure  (Fig. 
118).  The  history  of  the  treatment  of  hand  infections  is  too  often 
one  of  following  the  pus  by  making  additional  incisions.  Frequently 
an  infected  hand  is  operated  upon  two,  three,  or  even  more  times; 
whereas,  if  sufficient  drainage  is  established  at  the  first  incision, 
subsequent  openings  are  not  necessary. 

Ninety-fi.ve  per  cent,  of  the  infected  hands  requiring  two  or  more 
operations  occur  in  those  cases  given  office  treatment  (Fig.  119). 

Besides  reducing  disability,  a  number  of  these  serious  hand  in- 
fections would  have  resulted  in  permanent  deformities  if  this  radical 
form  of  treatment  had  not  been  adopted  early.  The  accompanying 
table  demonstrates  the  great  advantages  of  hospital  treatment  for 
hand  infections  as  compared  to  ambulatory  treatment: 


Table  20 

AMBULATORY  VERSUS  HOSPITAL  TREATMENT  OF  SERIOUS  HAND 

INFECTIONS 


Treated  at 
doctor's  office 
and  at  home 


Treated  at 
hospital 


Total  number .' 

Opened 

Not  opened ' 

Total  loss  of  time  from  work 

Average  loss  of  time,  per  case 

Permanent  disability,  as  loss  of  function  or  member 
Deaths 


253 
210 

43  or  17% 
2790  days 
11.02  days 

0 

0 


146 

78 

68  or  46.5% 

1088  days 

7.4  days 

21 

0 


From  a  study  of  the  above  facts,  I  am  positive  that  dangerous 
infections  can  be  prevented  and  disability  reduced  by  the  early  adop- 
tion of  hospital  treatment.     The  reasons,  therefor,  are: 

First,  the  patient  can  be  kept  absolutely  quiet  and  under  better 
control  than  at  home.  This  is  very  essential,  as  most  of  these 
infections  are  accompanied  by  a  low  grade  fever. 

Second,  continuous  hot  dressings  can  be  better  applied  by  a 
trained  nurse  than  by  the  relatives. 

Third,  better  operations  can  be  performed  because  of  the  general 
gas  anesthetic,  thus  reducing  the  length  of  treatment,  and  necessitat- 
ing fewer  repeated  operations. 

There  are  twelve  very  serious,  complicated  cases  of  hand  infections 

1 25  per  cent,  loss  of  function  by  stiff  middle  finger.     10  per  cent,  loss  of  function 
by  stiff  thumb. 


586  INDUSTRIAL    MEDICINE    AND    SURGERY 

from  this  series  which  are  not  included  in  the  above  table,  as  these 
were  first  given  home  treatment,  usually  by  their  family  physician, 
and  later,  as  a  final  resort,  came  under  our  care  at  the  hospital.  The 
serious  results  of  this  delayed  treatment  are  conclusively  demonstrated 
by  the  following  table: 


Fig.  120. — A  deformed  hand  the  result  of:  a,  Neglected  nail  scratch — failed  to 
use  iodin;  b,  neglected  early  surgical  care;  c,  poor  surgical  judgment — a  small  incision 
when  through  and  through  drainage  was  indicated. 

Table  21 

SERIOUS,  COMPLICATED  CASES  TREATED  AT  HOME  AND  TAKEN  TO 
HOSPITAL  AS  FINAL  RESORT 

Total  number 12 

Opened 12 

Total  loss  of  time  from  work 379  days 

Average  loss  of  time,  per  case 31.5  days 

Permanent  disability,  loss  of  function  or  member 5^ 

Deaths 0 

A  short  resume  of  two  of  these  cases  is  typical  of  the  entire  series 
of  twelve  hand  infections. 

Miss  K.,  17  years  old,  pricked  the  middle  finger  of  her  right  hand 
with  a  pin  on  January  5,  1914.  This  was  two  days  after  her 
employment.  One  of  the  witnesses  suggested  the  use  of  iodin,  but 
the  patient  did  not  think  this  necessary.  January  10,  five  days 
later,  she  reported  to  the  doctor's  office  with  marked  lymphangitis  of 

1  First  joint  index  finger  right  hand  stiff,  one  case. 
First  and  third  fingers  of  right  hand  are  flexed  and  stiff,  one  case. 
Four  fingers  of  right  hand  slightly  flexed  and  stiff,  one  case. 
Index  finger  left  hand  amputated,  one  case. 
Index  finger  right  hand  amputated,  one  case. 


HAND    INFECTIONS 


587 


the  arm  and  considerable  induration  about  tlie  axilla,  which  extended 
onto  the  chest  wall,  subclavicularly  and  back  to  the  border  of  the 
scapula.  Swelling  was  quite  firm  and  tender,  but  no  inflammatory 
reaction  of  the  skin  was  present.  Temperature  was  102°;  pulse  100. 
Had  a  slight  tonsillitis  and  pharyngitis,  but  otherwise  the  general 
examination  was  negative.  There  was  no  localized  infection  about  the 
point  of  injury.     The  patient  was  sent  to  the  hospital  and  under  a 


tittiS^KiHi^l^l^^^ 


Fig.  121. 

general  anesthetic  the  axillary  and  the  shoulder  absesses  were  incised 
at  three  different  points,  and  tube  and  gutta-percha  drainage  inserted. 
At  least  8  ounces  of  thin,  yellowish  pus  was  evacuated.  Large  hot 
boracic  dressings  were  applied  to  the  site  of  operation  and  a  second 
large  hot  dressing  applied  from  the  fingers  to  the  axilla  over  the  site 
of  the  lymphangitis.  Subsequent  course:  In  spite  of  the  evacuation 
of  the  pus,  the  temperature  continued  to  rise.     The  second  day  the 


Fig.  122. 
Figs.   121  and  122. — Show  a  deformed  middle  finger  following  a  neglected  splinter 
■wound."     This  finger  was  later  amputated  in  order  to  obtain  a  better  economic  end- 
result. 


temperature  was  103°,  pulse  120;  third  day,  1033-^°,  pulse  120;  fourth 
day,  105°,  pulse  140.  The  patient  was  exceedingly  sick  and  showed 
all  the  signs  of  a  general  systemic  infection.  The  fifth  day,  tempera- 
ture was  104°,  pulse  120;  the  sixth  day,  temperature  100°  to  102°; 
and  from  this  time  on  it  gradually  subsided,  until  at  the  end  of  two 
>  weeks  it  reached  normal  and  remained  there.     On  the  third  day,  a 


588  INDUSTRIAL    MEDICINE    AND    SURGERY 

stock  streptococcus  vaccine  was  injected,  and  on  the  fourth  day,  a 
small  dose  (50  million)  of  autogenous  vaccine,  which  had  been  pre- 
pared, was  administered.  A  slightly  larger  dose  of  autogenous  vac- 
cine was  given  on  the  sixth  day,  and  again  on  the  ninth  day.  These 
vaccines  were  repeated  every  four  days  for  four  more  doses.  She  left 
the  hospital  at  the  end  of  three  and  one-half  weeks,  and  recovery 
was  complete  at  the  end  of  five  weeks.  The  neglect  of  this  minor 
injury  and  the  late  reporting  after  the  trouble  had  started  were  the 
chief  reasons  for  this  girl's  serious  sickness. 

Mr.  E.,  an  old  employee,  received  a  slight  contusion  of  the  hand 
on  March  4,  1912.  The  cause  of  the  accident  was  unknown.  He 
had  been  under  the  care  of  his  family  physician  because  he  did  not 
think  his  work  was  responsible  for  the  injury.  The  hand  at  first 
became  swollen,  then  the  forearm,  which  was  badly  inflamed  and  very 


Fig.  123. — A  deformed  hand  following  a  cellulitis  of  the  forearm.  This  man  was- 
treated  in  his  home  by  his  family  physician  for  two  weeks.  Numerous  small  incisions 
were  made  without  adequate  drainage.  Recovery  did  not  occur  until  he  was  taken  to 
the  hospital  and  the  deep  abscesses  drained.  This  temporizing  treatment  caused 
four  months  disability  and  the  permanent  loss  of  function  in  the  hand. 

tender.  This  swelKng  increased  until  his  family  physician  was  called 
on  the  fourth  day.  Three  small  incisions  were  made  on  the  flexor 
surface  of  the  forearm  and  were  extended  through  the  skin  to  the 
fascia.  A  little  serous  exudate  was  found,  but  no  pus.  These  incisions 
became  infected,  and  superficial  abscesses  developed  on  the  forearm 
during  the  next  ten  days.  These  were  opened  and  drained  by  small 
incisions.  The  swelhng  in  the  arm  increased  to  an  immense  size 
and  the  entire  forearm  assumed  a  dark-red,  brawny  appearance. 
The  patient  came  under  my  care  March  18  and  was  taken  to  the 
hospital.  A  diagnosis  of  diffuse  cellulitis  of  the  forearm  was  made, 
with  large  collections  of  pus  in  both  the  ulnar  and  radial  bursse 
and  the  intramuscular  spaces.  Under  a  general  anesthetic,  large 
incisions  were  made  at  each  side  of  the  forearm,  just  above  the  wrist- 


HAND    INFECTIONS 


589 


joint,  and  the  ulnar  and  radial  bursse  drained  by  through-and- 
through  drainage.  A  large  incision  was  then  made  through  the  upper 
two-thirds  of  the  forearm,  shghtly  to  the  ulnar  side  of  the  middle 
of  the  flexor  surface.  From  this  incision,  all  intramuscular 
abscesses  were  opened  and  drained.  Infection  was  found  to  be  a 
staphylococcus  pyogenes  aureus,  and  autogenous  vaccines  were  made 
and  used  for  several  weeks.     This  man  ran  a  temperature  from  99° 


Fig.  124. — Deformed  hand  following  severe  hand  infection  from  nej^lected  pin  prick. 

to  102°,  with  a  weak  thready  pulse  of  110  to  130  for  at  least  six  weeks. 
He  gave  the  typical  picture  of  sepsis.  Acute  nephritis  developed, 
but  gradually  disappeared  with  recovery  from  his  infection.  For 
several  days  we  despaired  of  this  man's  life.  Recovery  was  prac- 
tically complete  about  the  middle  of  June,  some  three  months  later. 
Permanent  deformities  remain  in  this   case.     His  four  fingers  are 


-Hi 

- 

■p^ 

Fig.  125. — Same  as  Fig.  115  three  months  later.     This  deformity  was  overcome  by  the 

constant  use  of  a  hammer. 

flexed   about   25  per  cent,  and  cannot  be  completely  extended  nor 
closed. 

This  man's  long  disabihty,  loss  of  function  in  the  fingers,  and  the 
narrow  escape  from  death  were  all  the  result  of  neglecting  a  simple 
injury,  trying  ambulatory  treatment  when  hospital  treatment  should 
have  been  instituted  together  with  inadequate  drainage  during  the 
early  course  of  the  disease  (Fig.  123). 


590 


INDUSTRIAL   MEDICINE    AND    SURGERY 


The  remainder  of  the  cases  in  this  group  all  neglected  prophy- 
lactic measures  at  the  time  of  the  minor  injury;  a  few  were  given 
first  aid  by  fellow  employees,  as  attempted  removal  of  a  splinter  from 
the  hand,  in  which  case  a  portion  of  it  was  left  in ;  all  reported  to  the 
doctor  from  three  days  to  one  month  after  receiving  their  injuries; 
and  four  were  given  office  treatment  by  their  family  physicians 
for  a  few  days  before  being  sent  to  the  hospital.  The  five  cases  of 
permanent  deformities,  two  with  loss  of  fingers,  are  the  direct  result  of 
the  above  negligence. 

ECONOMIC  VALUE  OF  PROPER  DIAGNOSIS  OF  LOCATION  OF  PUS  AND 
PROPER    SURGICAL  INTERFERENCE  IN  HAND  INFECTIONS 

Many  cases  of  prolonged  disabihty  and  also  of  permanent  defor- 
mities result  from  a  wrong  diagnosis  of  the  type  of  infection,  a  lack 
of  understanding  as  to  the  location  of  the  pus,  and  inadequate  sur- 
gical interference — either  too  small  incisions,  or  at  times  too  large 


Fig.   126. — A  lateral  incision,  instead  of  on  the  flexor  surface,  over  the  tendon,  fur- 
nishes better  drainage  and  prevents  deformity. 


or  too  many  incisions.  Some  of  our  cases  of  serious  deformities  come 
under  this  heading.  Kanavel  has  demonstrated  conclusively  that 
there  are  certain  definite  spaces  where  infection,  entering  at  various 
points  on  the  hand,  tends  to  spread.  The  most  important  of  these 
spaces  are: 

1.  The  synovial  sheaths  about  the  tendons — the  commonest  site 
for  the  more  serious  forms  of  hand  infections  (Fig.  126). 

2.  The  lumbrical  and  subaponeurotic  space  at  the  edge  of  the  palm,, 
where  the  so-called  ''collar-button"  abscesses  form. 


HAND    INFECTIONS  591 

3.  The  thenar  space. 

4.  The  middle  palmar  space. 

5.  The  hypothenar  space. 

6.  The  radial  bursa. 

7.  The  ulnar  bursa. 

Through  the  last  two  spaces,  infections  usually  spread  from  the 
hand  to  the  forearm. 

A  knowledge  of  these  spaces  and  the  location  of  injuries  that  usu- 
ally lead  to  their  involvement  should  be  had  to  properly  open  and 
drain  these  most  serious  types  of  hand  infections.  To  know  the  re- 
lations and  boundaries  of  these  various  spaces  is  just  as  important  as 
it  is  to  know  where  to  enter  the  abdomen  for  the  appendix  or  to  reach 
the  gall-bladder.  In  other  words,  infections  about  the  fingers  and 
hand  have  too  long  been  considered  of  rather  minor  importance  and 


FiG.  127. — A  "collar-button"  abscess  from  a  neglected  infected  callous. 

have  been  treated  accordingly,  whereas  they  must  be  recognized  as 
very  grave,  serious  conditions  and  must  be  studied  and  treated  by 
the  most  approved  surgical  procedure.  Every  possible  adjunct, 
both  locally  and  constitutionally,  must  be  employed  to  hasten  re- 
covery and  prevent  a  spread  of  the  infection. 

A  classification  of  the  various  types,  as  to  location,  of  the  411  cases 
of  hand  infections  which  were  serious  enough  to  cause  disability  will 
give  the  relative  frequency  of  the  involvement  of  these  different 
spaces. 


592  INDUSTRIAL   MEDICINE    AND    SURGERY 

I.  The  types  of  hand  infections,  named  in  their  order  of  frequency,  which 
were  given  ambulatory  treatment: 

(o)  Paronychia 90 

(b)  Superficial  or  subepithelial  abscesses 72 

(c)  Abscesses  in  superficial  connective- tissue  spaces — cellulitis  of  hand 45 

(d)  Carbuncular  infections 20 

(e)  Lymphangitis  of  arm  from  hand  injury 13 

(f)  Felons 10 

(g)  Collar-button  abscesses  (distal  edge  of  palm) 3 

Total •....: 253 

II.  The  types  of  hand  infections,  named  in  their  order  of  frequency,  which 
were  given  hospital  treatment: 

(a)  Lymphangitis  of  arm  from  hand  injuries. . .  .  .  : 59 

(b)  Felons 24 

(c)  Tenosynovitis 24 

(d)  Abscesses  in  superficial  connective-tissue  spaces — cellulitis  of  hand 14 

(e)  Collar-button  abscesses 7 

(/)  Carbuncular  infections 5 

(g)  Middle  palmar  space  infections 5 

{h)  Paronychia 3 

(i)  Thenar  space  infections 3 

(j)  Hypothenar  space  infections 2 

Total 146 

III.  The  twelve  very  serious  cases  where  active  treatment  was  adopted  late 
were  characterized  by  having  more  than  one  space  involved,  or  some  other  form 
of  complication,  as  follows: 

a)  Diffuse  cellulitis  of  hand  and  arm  and  general  sepsis. 

b)  Middle  palmar  space  and  ulnar  bursa. 

c)  Tenosynovitis  and  necrosis  of  bone  of  index  finger. 

d)  Tenosynovitis  and  multiple  abscesses  of  arm. 

e)  Diffuse  cellulitis  of  hand  and  arm. 

/)  Tenosynovitis,  middle  palmar  abscess,  and  necrosis  of  bone. 

g)  Thenar  space,  middle  palmar  space,  and  ulnar  bursa. 

h)  Tenosynovitis  and  middle  palmar  space. 

i)  Superficial  abscess  of  hand,  lymphangitis,  and  axillary  abscess. 

j)   Superficial  abscess  of  hand,  lymphangitis,  axillary  abscess,  and  subclavicular 

and  subscapular  abscess  of  chest  wall  and  general  sepsis. 
k)  Lymphangitis,  axillary  abscess,  and  subclavicular  abscess  of  chest  wall. 
I)  Lumbrical  space  abscess  and  necrosis  of  bone. 

Besides  definitely  ascertaining  the  location  of  the  pus,  a  differ- 
ential diagnosis  of  the  type  of  infection  should  be  made  in  every  case 
showing  signs  of  becoming  serious.  In  this  way  complications  which 
may  be  expected  from  more  virulent  organisms  can  be  anticipated 
and  guarded  against.  Again  chronic  infections  which  have  resisted 
all  treatment  may  be  found  due  to  some  obscure  condition  or  rare 
organism.     For  example,  a  young  man  scratched  his  forearm  upon  a 


HAND    INFECTIONS 


593 


piece  of  tin  nailed  to  a  bin.  It  became  infected  and  resisted  all  treat- 
ment for  a  period  of  two  weeks.  The  first  cultures  were  reported  as 
negative.  Finally  cultures  were  again  made  and  were  reported  as 
*'no  growth"  after  forty-eight  hours.  After  seventy-two  hours,  how- 
ever, the  laboratory  assistant  reported  that  we  were  dealing  with  a 
case  of  Sporotrichosis  caused  by  the  Sporothrix  Schenkii.  The  line 
of  treatment  was  modified  accordingly  and  recovery  resulted  shortly 
afterward .     (See  Fig.  1 28 . ) 


Fig.   128. — Case  of  sporotrichosis  (sporothrix  Schenkii).      Failure  to  diagnose  the  cause 
of  this  infection  delayed  recovery  at  least  two  weeks. 


The  operative  procedures  and  the  general  and  local  treatment 
required  for  hand  infections  is  dealt  with  in  detail  by  Kanavel  in  his 
book  on  "  Hand  Infections. "  Likewise  many  interesting  contributions 
on  this  subject  have  been  made  to  the  medical  literature  as  a  result  of 
the  various  experiences  in  war  surgery.  The  reader  is  referred  to 
these  sources. 

Both  Dr.  Sherman  of  the  Carnegie  Steel  Company  and  Dr.  Corwin 
of  the  Colorado  Fuel  and  Iron  Company  have  introduced  the  Carrel- 
Dakin  method  of  combating  infections  into  their  industrial  surgery 

38 


594 


INDUSTEIAL    MEDICINE    AND    SURGERY 


S^l>fc4    .  ill 


Fig.   129. — Cellulitis  of  the  arm  from  an  industrial  injury  being  treated  by  the  Carrel- 

Dakin  method. 


Fig.  130. — Sterile  instruments  and  tubes  are  handed  to  doctor  by  nurse  with  sterile 

instruments. 


HAND    INFECTIONS 


595 


and  claim  most  excellent  results.  These  two  surgeons  visited  France 
and  made  personal  studies  of  this  method  of  treatment  which  may- 
account  for  their  results.     It  is  quite  evident  that  many  of  the  un- 


FiG.  131. — Smear  of  wound  being  taken  for  bacterial  count. 

favorable  reports  concerning  the  Carrel-Dakin  treatment  are  due  to 
lack  of  familiarity  of  applying  the  method  (Figs.  130  to  135). 

The  Dichloramine-T  treatment  of  infections  has  also  come  into 


Fig.  132. — Wound  with  Carrel  tubes  inserted  ready  for  external  dressings. 

prominence  since  the  war.  Dr.  Lee  of  Philadelphia  has  published 
numerous  reports  concerning  its  use.  In  my  own  chnic  this  has 
proven  very  efficacious  in  securing  the  more  rapid  recovery  of  many 


596 


INDUSTRIAL    MEDICINE    AND    SURGERY 


chronic  infections,  as  for  instance  the  infected  abrasions  or  a  periostitis 
with  ulcer  formation  over  the  shin  bone.  It  is  an  excellent  method 
of  treatment  for  old  chronic  hand  infections. 


Fig.   133. — Gauze  taken  from  sterile  package  with  sterile  instruments. 

Many  surgeons  treat  these  hand  infections  by  the  continuous  hot 
boric  dressing  method.     Results  depend  upon  the  frequent  changing 


Fig.   134. — Sterile  gauze  applied  to  the  wound. 

of  these  dressings  otherwise  they  soon  become  saturated  with  the 
infected  pus — truely  pus  dressings  instead  of  boric  dressings. 


HAND   INFECTIONS  597 

Adequate  drainage,  hot  dressings  frequently  changed,  with  immo- 
bilization of  the  infected  part  have  proven  very  beneficial  in  the  past. 
Careful  records  and  comparison  of  results  between  this  and  the  newer 
principles  regarding  infection  treatment  are  necessary  before  determin- 
ing which  will  give  the  desired  end — the  quickest  recovery  with  the 
least  loss  of  function. 


Fig.   135. — Bandaging  wound  over  the  tubes  and  dressing.       {Clinic  of  Dr.  Corwin.) 

CONCLUSIONS 

The  treatment  of  hand  infections,  therefore,  in  order  to  give  the 
best  results  from  every  viewpoint  must  include: 

1.  The  proper  preventive  measures,  especially  the  prophylactic  use 
of  tincture  of  iodin  and  the  early  reporting  of  all  minor  injuries. 

2.  The  treatment  of  hand  infections  as  a  serious  surgical  condition 
from  their  inception,  and  whenever  indicated  the  adoption  of  hospital 
treatment  early. 

3.  The  proper  and  early  diagnosis  of  the  type  and  nature  of  in- 
fection and  the  exact  location  of  the  pus. 

4.  A  proper  incision  of  the  abscess  in  order  to  establish  adequate 
drainage  and  yet  not  spread  the  infection  to  other  spaces. 

5.  The  immobilization  of  the  infected  part  and  the  frequent 
changing  of  the  dressing  whatever  method  is  used. 


CHAPTER  XXXVII  i 

FRACTURES  ^ 

Prior  to  the  war  industrial  surgery  furnished  one  of  the  greatest 
opportunities  for  advancement  in  the  handhng  of  fracture  cases.  If  we 
combine  with  our  past  experiences  the  vast  material  concerning 
fracture  treatment  which  has  accumulated  during  these  four  years  of 
war,  still  greater  advances  in  this  branch  of  surgery  will  be  made. 

Fractures  undoubtedly  contribute  more  to  the  absentee  rate  among 
injured  employees  than  any  other  type  of  injury.  The  claims  for 
permanent  disability  are  also  more  frequently  the  result  of  fractures 
than  from  any  other  cause.  Thus  it  is  evident  that  greater  attention 
must  be  paid  to  the  handhng  of  fracture  cases  from  the  standpoint  of, 
first,  their  prevention,  and  second,  their  treatment  from  an  economic 
point  of  view. 

The  number  of  fracture  cases  can  be  greatly  reduced  in  any  industry 
by  the  methods  described  for  preventing  accidents.  In  addition  to 
this  the  spirit  of  prevention  must  invade  the  entire  working  force  so 
that  every  employee  will  be  on  the  lookout  for  obstructions  and  pit- 
falls which  can  cause  a  fellow  employee  to  fall  and  injure  himself.  In 
my  experience  falls  have  been  responsible  for  70  per  cent,  of  the 
fracture  cases  presenting  themselves  for  treatment.  During  the  first 
'year  of  the  war  out  of  24,000  injuries  due  to  accidents  from  industrial 
causes  in  the  army,  12,626  were  due  to  falls,  and  of  this  number  2,147 
sustained  fractures. 

Therefore,  a  campaign  directed  toward  the  removal  of  obstructions, 
the  protection  of  high  places,  the  fencing  in  of  excavations,  the  testing 
of  ladders  and  elevations  before  using  them,  the  repair  of  broken  floors 
and  sidewalks,  the  proper  attention  to  the  shoes  of  employees,  and  the 
eradication  of  ah  other  things  making  falls  possible,  will  certainly 
prevent  at  least  50  per  cent,  of  the  fracture  cases. 

The  following  are  the  high  hghts  in  the  economic  treatment  of 
fractures : 

1.  The  use  of  the  a;-ray.  Every  .fracture  should  be  a;-rayed  before 
and  after  it  is  "set"  and  always  from  two  or  more  different  angles. 
This  is  often  neglected  because  of  the  expense  attached  to  the  procedure, 
but  one  cause  of  faulty  functional  result  will  cost  more  than  a;-raying 
every  fracture  case  for  a  year.  The  reduction  and  coaptation  of  many 
broken  bones  can  be  facihtated  by  the  use  of  the  fluoroscope.     Every 

598 


FRACTURES 


599 


industry  where  a  fair  number  of  fractures  occur  among  the  employees 
should  have  a  surgical  dispensary  equipped  with  an  a;-ray  apparatus. 

2.  The  immediate  immobilization  of  the  fractured  member.  The 
improved  results  in  fracture  work  in  many  industries  has  been  due  to 
the  presence  of  a  surgeon  on  the  job,  who  could  properly  immobilize 
the  part  before  transportation  was  attempted.  This  principle  has 
been  further  strengthened  by  the  work  of  the  regimental  surgeons  at 
the  front.  When  ^  surgeon  is  not  available  then  first  aid  assistants 
should  be  thoroughly  trained  in  these  methods  of  fixation  and 
transportation. 

Major  Horace  Allen  (The  MiHtary  Surgeon,  April,  1918)  has  made 
a  suggestion  relative  to  the  proper  stretcher  for  severe  fractures  of  the 


Fig.   136. — A  stretcher  table.     {Allen,  from  The  Military  Surgeon.) 
Such  a  stretcher  would  enable  the  transportation  of  a  severe  accident  case  to  the" 
doctor's  office  where  emergency  treatment   could    be  rendered,  and  later  transported 
to  the  hospital — all  without  unnecessarily  disturbing  the  patient. 


spine,  pelvis  or  femur  which  can  very  well  be  adapted  to  industrial 
surgery.  It  has  been  customary  to  carry  these  severe  fracture  cases  to 
the  surgical  dispensary  where  emergency  care  is  rendered.  When  the 
ambulance  arrives  the  patient  is  transferred  to  the  ambulance  stretcher 
and  on  arriving  at  the  hospital  he  is  again  transferred  to  the  hospital 
bed.  These  movements  are  exceedingly  painful  to  the  patient  and  are 
liable  to  interfere  with  the  best  functional  results.  Alien  suggests 
using  a  padded  stretcher  with  legs  which  can  be  used  to  transport  the 
patient  and  also  as  his  bed  in  the  hospital  for  a  few  weeks.  He  claims 
that  the  patients  find  the  stretcher  bed  more  comfortable  than  a 
hospital  bed.     It  would  undoubtedly  facihtate  the  handling  of  the  case 


600 


INDUSTRIAL    MEDICINE    AND    SURGERY 


by  the  doctor  and  nurse.     Major  Allen  thus  describes  the  accompany- 
ing illustrations : 

"A  Htter  resting  on  four  sticks  passed  through  rectangular  holes 
in  the  tread  into  the  sockets  at  the  top  of  the  stirrups.  At  the  head 
and  foot  of  the  Htter  are  adjustable  extensions.  Near  the  head  end  is 
a  head  rest  which  is  automatically  locked  in  place  when  the  spreader 
bars  put  the  canvas  on  the  stretch.  In  the  middle  is  the  bed-pan, 
attached  to  the  canvas  in  such  a  way  that  it  has  to  be  open  when 
attached  and  has  to  be  closed  in  order  to  be  detached.  Near  the  foot 
end  is  a  substitute  for  the  Balkan  frame,  namely,  a  swinging  traveling 


Fig.  137. — The  practical  use  of  a  stretcher  lied  in  an  army  hospitaL     (From  a  Painting 

by  Thayer.) 

crane,  balanced  or  unbalanced,  capable  of  giving  any  variety  of  move- 
ments, or  standing  stationary.  It  can  be  attached  or  removed  in  less 
than  one  minute.  The  attachment  piece  crosses  underneath  the  poles 
of  the  htter." 

Some  of  the  possibilities  of  such  a  stretcher  bed  are  well  illustrated 
in  the  painting  "Why  Not"  by  Sergt.  Thayer,  of  the  Army  Medical 
Museum  (Fig.  137). 

Quicker  and  better  results  will  be  obtained  if  more  attention  is 
paid  by  surgeons  to  the  prompt  immobiUzation  of  fractures  and  to 
the  proper  facihties  for  their  transportation. 


FRACTURES  601 

3.  The  use  of  an  anesthetic  for  reducing  and  fixing  the  fracture. 

4.  The  early  use  of  passive  motion,  massage  and  muscular  ex- 
ercises in  all  fractures.  In  the  majority  of  broken  bones  after  they 
have  once  been  properly  set  and  fixed  it  is  perfectly  safe  to  gently 
loosen  the  splints  and  give  massage.  The  sooner  passive  motion  and 
then  active  motion  can  be  estabhshed  the  better  will  be  the  functional 
result.  For  this  reason  I  avoid  as  far  as  possible  the  use  of  the  circular 
plaster  cast  which  prevents  these  methods  of  maintaining  tone  and 
function  in  the  adjacent  muscles.  The  surgeon  treating  fractures  must 
not  be  content  to  put  them  up  in  a  cast  and  not  see  the  case  again  for 
a  month  or  six  weeks  when  the  cast  is  removed.  These  patients 
require  almost  daily  attention  to  obtain  the  best  results. 

5.  The  therapeutic  adjunct  of  "keeping  these  patients  busy" 
is  of  the  greatest  importance  in  shortening  their  period  of  disability. 
If  the  fracture  is  of  such  a  nature  as  to  confine  the  patient  to  bed,  then 
"bedside  occupations"  should  be  provided.  He  should  be  given 
regular  exercises  in  bed  and  taught  how  to  exercise  the  muscles  in  the 
injured  member  without  moving  the  adjacent  joints.  For  the  ambu- 
latory cases  work  is  the  best  medicine.  These  men  tend  to  develop 
habits  of  loafing  and  postpone  as  long  as  possible  their  return  to  work. 
If,  however,  they  are  assigned  easy  tasks  at  the  plant  they  can  often 
return  to  work  within  a  week  after  the  injury,  before  the  habit  of 
loafing  has  developed.  Thus  I  seldom  allow  my  cases  of  fractured 
arm  to  remain  away  from  work  until  recovery  is  completed.  Dr. 
Farnum  states  that  80  per  cent,  of  all  his  fracture  cases  are  placed 
at  some  light,  useful  work  within  a  week  after  the  accident  and  the 
period  of  disability  and  the  actual  time  the  patient  is  under  treatment 
have  been  greatly  reduced  thereby. 

6.  The  judicious  and  early  use  of  massage,  mechanotherapy,  and 
hydrotherapy  will  be  found  of  the  greatest  value  in  overcoming  the 
sweUing  and  sluggish  circulation  in  the  extremity  which  has  been  im- 
mobilized for  some  time.  We  have  followed  a  very  uneconomical 
practice  in  allowing  these  conditions  to  gradually  disappear  of  their 
own  accord.  Proper  active  treatment  of  a  fracture  throughout 
will  eHminate  the  chronically  swollen  extremity  which  worries  the 
patient  so  much  and  tends  to  prolong  his  disabiHty  weeks  longer  than 
is  necessary. 

For  the  treatment  of  specific  fractures  the  reader  is  referred  to 
any  one  of  the  excellent  text-books  on  this  subject.  Nevertheless 
so  many  advances  have  been  made  in  the  treatment  of  fractures 
during  the  war  that  it  is  desirable  to  point  out  the  most  important 
improvements  which  are  apphcable  to  industrial  surgery. 

Dr.  Irving  Clark,  of  Worcester,  Mass.,  had  an  unusual  experience 
in  fracture  work  during  his  eight  months  service  with  the  American 


602  INDUSTRIAL    MEDICINE    AND    SURGERY 

Red  Cross  in  France.  He  is  also  familiar  with  the  problems 
which  confront  the  industrial  surgeon.  Therefore,  the  author  per- 
suaded him  to  write  the  following  article  which  is  pregnant  with 
suggestions  applicable  to  this  field  of  surgery: 

"The  treatment  of  fractures  in  industrial  surgery  may  be  divided 
into  the  treatment  of  simple  and  compound  fractures.  The  treatment 
of  simple  fractures  is  divided  into  emergency  and  permanent  treatment. 

"Fractures  occurring  in  industry  are  more  severe  than  in  ordinary 
practice  because  of  the  frequency  of  direct  violence  as  a  cause. 

EMERGENCY  TREATMENT 

"Emergency  treatment,  while  it  can  be  carried  out  by  a  foreman 
trained  in  first  aid,  can  in  most  cases  be  done  better  by  the  industrial 
surgeon. 

"The  emergency  treatment  consists  of  immediate  immobilization 
in  approximate  alignment.  This  is  obtained  by  traction,  and  fixation, 
the  fixation  being  so  managed  that  the  patient  may  be  transferred  to 
the  hospital  with  a  minimiim  of  pain  and  shock.  The  permanent 
treatment  consists  in  complete  reduction  and  immobilization.  In  the 
treatment  of  fractures,  there  are  four  basic  rules  which  are  always 
safe  to  follow :  Always  have  a  good  a;-ray.  Always  use  a  general  anes- 
thetic. When  reducing  endeavor  to  obtain  an  interlocking  of  the 
fragments  end  to  end,  and  immobilize  in  the  position  which  will  hold 
them  in  alignment  with  the  least  strain.  When  one  of  the  fragments 
is  held  in  a  certain  position  by  muscular  spasm,  the  other  fragment 
should  be  approximated  to  it  and  held  in  alignment  with  it  by  thesphnt. 

"In  a  brief  chapter  such  as  this,  it  is  impossible  and  unnecessary 
to  consider  the  classic  fractures,  their  reduction  and  the  various  forms 
of  spHnts  which  can  be  used  for  their  retention.  Information  of  the 
most  complete  kind  can  be  obtained  in  such  text-books  as  Scudder's 
'Treatment  of  Fractures,'  Moorhead's  'Traumatic  Surgery,'  Stim- 
son's  'Fractures'  and  Cotton's  'Fractures  of  the  Joints.'  Our  efforts 
here  will  be  to  point  out  slight  modifications  of  standard  dressings  and 
splints,  and  particularly  to  bring  out  the  most  recent  work  done  in  the 
war  hospitals  where  fractures  play  a  very  important  part. 

"The  industrial  surgeon  will  do  well  to  hmit  his  emergency  splints 
to  as  small  a  number  as  possible  and  not  only  know  himself,  but  have 
trained  his  assistants,  in  the  rapid  application  of  each  type.  The  fol- 
lowing Hst  of  splints  may  prove  useful  as  a  basis  :^ 

1  At  the  beginning  of  the  war  over  200  different  types  of  splints  were  used  by 
the  English.  A  committee  on  standardization  first  reduced  this  number  to  112 
and  later  to  less  than  50.  The  medical  department  of  the  A.  E.  F.  early  stand- 
ardized the  fracture  work  in  our  army  so  that  eight  varieties  of  splints  made  up 
the  total  used.     (Author's  note.) 


FRACTURES  603 

"  1.  Six  basswood  splints  cut  in  16-inch  lengths — trade  width.  It 
is  well  to  have  these  all  ready  thickly  padded  with  sheet  wadding. 
For  use  in  fractures  of  forearm. 

"  2.  Two  Thomas  hip  spUnts,  army  pattern.  For  use  in  fractures 
of  the  femur.  The  sphnt  consists  of  a  padded  ring,  slightly  ovoid  in 
shape,  set  upon  two  iron  wire  rods  at  an  angle  of  55  degrees  with  the 
outer  rod.  The  rods  are  three-eighths  of  an  inch  in  diameter.  At  the 
inner  and  shorter  of  these  two  rods  the  ring  is  twice  as  heavily  padded 
as  at  the  outer,  and  the  ring  is  symmetrically  depressed  at  either  side  of 
the  inner  rod  to  form  a  concavity  which  hugs  the  ischial  ramus  and 
fits  snugly  around  the  ischial  tuberosity.  The  long  and  short  diam- 
eters of  this  ring  vary  since  the  splint  as  used  by  the  British  army 
comes  in  several  sizes,  but  a  ring  of  average  size  -measures  across  the 
long  diameter  93=^^  inches,  and  across  the  short  diameter  9  inches. 
The  outer  rod  descends  from  the  ring  vertically  for  2}^^  inches  and 


Fig.   138. — Thomas  splint. 

then  incKnes  toward  the  inner  rod.  At  the  starting  point  of  the  in- 
ner rod  the  two  wires  are  83^^  inches  apart  and  at  the  bottom  they 
are  continuous  in  an  indented  or  notched  end,  33^^  inches  in  width, 
about  which  the  traction  bands  are  wound  and  knotted.  The  out- 
side rod  is  47  inches  in  length  and  the  inside  rod  42  inches  in  length, 
The  space  between  the  rods  may  be  varied  by  bending  them  outward 
and  inward.     If  desired  the  splints  may  be  bent  at  the  knee  (Fig.  138) . 

"  3.  Twelve  wooden  tongue  depressors,  thickly  padded.  For  frac- 
tiu-ed  fingers. 

"Supphes  for  use  in  emergency  treatment  of  fractures. 

"  1.  Twelve  bandages  3  inches  wide — 6  gauze,  6  musHn, 

"2.  Six  packages  large  safety  pins. 

"3.  Two  folded  pillow  cases  for  axillary  pads. 

"4.  Four  triangular  slings,  army  design. 

"  5.  One  roll  of  Z.  0.  adhesive  plaster,  5  yards  X  12  inches.  For 
fracture  of  clavicle  and  for  retention  of  basswood  splints. 

"6.  Two  pillows  with  pillow  cases.     For  leg  fractures. 


604 


INDUSTRIAL    MEDICINE    AND    SURGERY 


''  The  standard  methods  of  applying  these  splints  and  suppUes  to 
the  most  frequent  fractures  will  be  found  in  the  Red  Cross  First  Aid 
Manual. 

"There  are  certain  points  about  their  application  which  are  im- 
portant. Little  difficulty  will  be  experienced  with  the  emergency 
treatment  of  fractures  of  the  clavicle  and  humerus.  These  can  be 
treated  in  the  classic  way  with  slings  and  bandages. 

"Fractures  of  the  forearms  should  always  be  splinted  with  double 
boards  and  the  forearm  should  be  supported  at  right  angles  to  the 
humerus. 


Fig.   139. — Strapping  of  chest  for  fractured  ribs.      Note  that  plaster  extends  two-thirds 
around  the  body  and  that  the  straps  overlap,  being  applied  from  below  upward. 

"Fractures  of  the  ribs  should  be  at  once  immobilized  with  adhesive 
plaster.  The  strips  should  be  four  inches  wide,  and  long  enough  to 
encircle  two-thirds  of  the  chest  (Fig.  139). 

"The  strapping  should  be  applied  from  below  upward,  each  strip 
overlapping  the  one  below.  Too  much  snugness  cannot  be  obtained. 
The  strap  should  be  put  on  with  pressure. 

"Fractures  of  the  thigh  should  be  treated  by  the  Thomas  hip  splint. 
The  method  of  applying  this  is  as  follows:  With  the  patient  lying  in  a 
comfortable  position  apply  traction  to  the  injured  leg.  'Adequate 
and  comfortable  traction  can  be  secured  with  a  bandage,  which  is  al- 
ways at  hand  and,  therefore,  most  strongly  recommended.  Various 
ingenious  substitutes  have  been  suggested  and  employed  and  are  wor- 


FRACTURES 


605 


thy  of  mention.  A  screw-eye  may  be  inserted  in  the  heel  of  the  boot ; 
a  nail  or  skewer  may  be  pressed  through  the  shank  of  the  shoe  and 
cords  attached  to  its  projecting  ends;  a  horseshoe  shaped  wire  with 
inward  facing  prongs  can  be  hooked  over  the  welt  of  the  shoe  on  both 
sides  and  a  traction  cord  be  attached  to  the  ring  of  the  horseshoe. 
These  methods  demand  special  articles  sure  to  be  lost  or  mislaid,  while 
bandage  traction  is  always  available.' 

"The  technic  of  the  application  is  important.  Take  a  double 
length  of  four-inch  bandage  a  yard  and  a  half  long.  Place  the  middle 
of  this  traction  band  back  of  the  shoe  just  above  the  counter.  Wrap 
both  ends  across  the  instep  and  round  under  the  sole  in  the  usual 
figure-of-eight  manner.  Bring  each  end  up  on  its  respective  side  and 
carry  its  under  the  lateral  part  of  the  bandage  behind  the  malleolus, 
then  over  this  bandage  and  directly  downward,  thus  providing  two 


Fig.   140.- 


-Thomas  splint  hastily  applied  for  emergency, 
for  traction. 


Note  hitch  in  region  of  ankle 


lateral  traction  bands.  The  loops  should  be  well  back  of  the  malleoli 
so  that  the  line  of  traction  is  behind  the  ankle-joint.  A  generous  pad 
should  be  placed  over  the  instep  beneath  the  crossing  of  the  bands  to 
prevent  pressure.  It  must  be  borne  in  mind  that  grave  injuries  of  the 
leg  interfere  with  its  circulation  and  that  pressure  sores  develop  from 
incredibly  slight  trauma. 

"Slip  the  Thomas  splint  on  gently  and  fit  the  ring  well  at  the  ischial 
bearing.  Carry  each  traction  band  half  around  the  corresponding 
uprights,  passing  one  over  and  one  under  its  upright,  and  then  bring 
each  one  in  opposite  directions  once  about  the  notched  iron  piece  at 
the  lower  end  of  the  splint  and  tie  with  square  half  bow-knot.  A  nail 
or  bit  of  wood  slipped  between  the  bands  below  where  they  have  been 
brought  about  the  uprights  may  be  twisted  as  in  a  Spanish  windlass 
to  increase  the  traction  at  will  (Figs.  140  and  141). 

"A  bandage  about  the  whole  splint  completes  the  dressing.     For 


606 


INDUSTRIAL    MEDICINE    AND    SURGERY 


speed,  this  may  be  applied  from  above  downward,  as  there  is  no  danger 
of  constricting  the  hmb  with  a  bandage  carried  outside  the  uprights 
of  the  sphnts. 

"A  coaptation  «plint  is  often  used  as  a  posterior  spKnt  to  increase 
the  support  of  the  thigh.  This  is  desirable  but  by  no  means  necessary, 
as  the  dressing  as  above  described  gives  adequate  and  comfortable 
support. 

"Transfer  to  the  Stretcher. — The  stretcher  should  be  provided  with 
a  heavy  spHnt  support  which  springs  on  to  the  side  bars.  The  patient 
should  be  carefully  lifted  on  to  the  stretcher  by  four  bearers.  The 
end  of  the  splint  should  be  slung  to  the  cross  bar  of  the  splint  support 
by  a  bandage,  so  that  the  leg  clears  the  stretcher,  and  also  tied  to  each 
upright  of  the  sphnt  support  to  prevent  side  sway.^ 


Fig.  141. — Thomas  splint  further  applied  before  the  application  of  bandage.  Note 
bandages  tied  around  leg  in  the  region  of  fracture  to  set  leg  on  sphnt.  A  further 
bandage  may  be  apphed  over  the  whole  for  additional  security,  but  the  rigging  as  shown 
is  sufficient  for  transportation  for  short  distances. 

"Fractures  of  the  leg  can  usually  be  comfortably  immobiUzed  by  a 
pillow  sphnt.  When  the  fracture  is  very  severe  and  there  is  much 
pain  and  displacement  the  Thomas  sphnt  should  be  used. 

"Pott's  fracture  and  fractures  of  the  foot  can  be  best  treated  by 
using  the  pillow  sphnt. 

PERMANENT  TREATMENT 
Fractures  of  Upper  Extremity 

"Fractures  of  Clavicle. — In  applying  the  classic  Sayre  adhesive 
plaster  dressing,  the  foUowing  shght  modifications  have  been  found 
of  advantage.  The  first  consists  of  a  pad  of  one  thickness  of  Saddler's 
felt  having  a  hole  cut  in  it  and  apphed  over  the  olecranon.  This 
prevents  the  cutting  of  the  adhesive  plaster  which  is  so  disagreeable. 

1  Major  Kendall  Emerson,  British  Jour,  of  Surgery,  September  12,  1918. 


FRACTURES 


607 


The  second  modification  consists  of  a  strip  of  adhesive  1^^"  wide 
which  surrounds  the  wrist  and  then  passing  over  the  affected  clavicle, 
sticky  side  down,  and  is  attached  to  the  broad  arm  strap  behind. 
A  pad  of  felt  over  the  affected  clavicle  helps  to  hold  the  fragments 
in  position  and  avoids  adhesive  plaster  pressure  (Fig.  142). 

"Fractures  of  the  Surgical  Neck  of  the  Humerus. — This  fracture 
is  a  fairly  common  one  and  has  received  considerable  attention  due 
to  the  difficulty  of  its  retention.  Jones  describes  its  reduction  and 
retention  as  follows: 

^^^ Treatment. — Traction  on  the  arm  in  the  axis  of  the  humerus, 
gradually  abducting  and  rotating  outward  till  the  arm  is  at  right 


Fig.  142. — Modification  of  Sayre  dressing  for  fractured  clavicle.  Note  pads  at 
elbow  and  over  clavicle  and  additional  strap  extending  from  wrist  over  clavicle.  The 
elbow  strap  is  not  put  on  in  this  case  in  the  classical  way  as  enough  raising  of  the  shoulder 
can  be  obtained  without  carrying  the  strap  across  the  back,  and  the  dressing  is  more 
comfortable  for  the  patient.     Note  raising  of  right  shoulder  in  cut. 

angles  to  the  body  or  even  straight  upward  parallel  to  the  side  of  the 
head,  will  disengage  the  lower  fragment  from  the  inner  side  of  the  upper 
fragment.  In  this  position  the  Hne  of  traction  of  the  pectorahs 
major,  latissimus  dorsi,  and  teres  major  is  in  the  axis  of  the  shaft, 
so  these  muscles  no  longer  exert  a  lateral  distorting  force. 

"  'While  an  assistant  is  extending  the  Kmb  in  this  way  the  surgeon 
with  his  hands  feels  when  the  bones  have  completely  disengaged.  He 
then  asks  the  assistant  to  relax  the  tension  on  the  hmb,  while  he  tries 
to  guide  the  ends  so  that  they  engage  end  to  end. 


608 


INDUSTRIAL    MEDICINE    AND    SURGERY 


'"If  they  do  engage,  they  can  often  be  gently  pressed  together  and 
made  to  lock  sufficiently  to  allow  the  arm  to  be  brought  down  to  the 
side  slowly  and  gently,  and  with  a  pad  in  the  axilla  the  arm  is  securely 
fixed  to  the  body,  with  the  elbow  bent  to  an  angle  of  forty-five  degrees 
and  the  wrist  slung  from  the  neck.  These  movements  should  be 
performed  with  gentleness  and  judgment  to  avoid  injury  to  nerves 
and  vessels. 

"'Experience  has  shown  that  once  this  maneuver  is  successfully 
accompUshed  the  ends  are  not  likely  to  disengage,  and  all  that  is  neces- 
sary is  to  wait  for  union  and  then  gradually  commence  movement. 

"  'If  the  shape  of  the  line  of  fracture  is  such  that  the  fragments 
will  not  lock  properly  and,  therefore,  disengage  when  the  arm  is  brought 


Fig.  143. — Thomas  arm  extension  splint  for  severe  fractures,  usually  compound, 
of  the  humerus.  Note  method  of  suspension  and  traction,  the  same  as  used  in  the 
Thomas  leg  splint.  {Manual  of  Splints  and  Appliances  for  the  Medical  Department 
of  the  United  States  Army,  1917.) 


down  to  the  side,  the  arm  must  be  fixed  in  the  abducted  position. 
In  this  position  the  line  of  traction  of  the  pectorals  and  latissimus  is 
practically  the  axis  of  the  limb,  and,  therefore,  will  only  pull  the  two 
ends  toward  each  other  and  not  laterally,  and  usually  the  fragments 
will  not  slip. 

"  'The  whole  arm,  shoulder  and  upper  hmb,  is  swathed  in  one  layer 
of  cotton-wool.  It  is  best  to  roll  up  a  whole  length  of  cotton-wool 
and  apply  it  like  a  bandage.  Over  this  plaster  bandage  is  applied 
to  the  arm  and  upper  part  of  the  chest,  rubbing  it  firmly  round  the 
shoulder  and  axilla  and  again  firmly  round  the  bony  points  about  the 
elbow.  A  proper  grip  of  the  condyles  of  the  humerus  prevents  shorten- 
ing of  the  limb;  to  make  sure  of  the  external  rotation  the  forearm  should 


FRACTURES 


609 


be  included;  if  the  elbow  is  bent  till  the  hand  is  behind  the  head, 
the  position  is  not  in  any  way  uncomfortable,  and  the  success  of  the 
functional  result  is  assured. 

**  'Two  lengths  of  strong  webbing,  like  horse-girths  or  something  not 
quite  so  wide,  one  round  the  axilla  and  fixed  on  the  opposite  side  of  the 
table,  and  the  other  over  the  top  of  the  shoulder  and  fixed  to  the 
bottom  of  the  table,  give  an  excellent  resistance  against  which  to 
pull.  A  roller  towel  or  folded  sheet  will  do,  but  being  more  bulky 
is  more  apt  to  get  in  the  way  of  the  surgeon's  hands  when  mani- 
pulating the  shoulder.'  '■ 

''The  aeroplane  splint  devised  at  the  former  American  Ambulance, 
Neuilly,  France,  is  extremely  good  in  these  cases,  allowing  motion 


Fig.  144. — Suspension  traction  method  of  treating  compound  fracture  of  the 
humerus  by  means  of  the  Balkan  frame,  h,  Plate  or  hook;  w,  weights;  a,  arm  suspen- 
sion band ;  h,  glued  traction  band.  {Manual  of  Splints  and  Appliances,  Medical  Depart- 
ment, U.  S.  A.) 


of  the  forearm  on  the  arm.  It  is,  however,  bulky  and  does  not  seem 
necessary  in  the  case  of  simple  fractures. 

"If  the  fracture  is  very  severe  with  much  comminution  there  is  no 
better  form  of  treatment  than  that  of  suspension  in  a  Balkan  frame. 
Continuous  traction  in  abduction  can  be  maintained  by  means  of  a 
Thomas  arm  splint  or  by  the  Blake  method  of  suspension  (Figs.  143 
and  144). 

"The  writer  when  visiting  the  large  fracture  center  of  the  French 
Army  at  Chateau  Thierry  was  told  that  all  fractures  of  the  humerus 
were  treated  by  a  simple  triangle  of  wood  which  fitted  snugly  in  the 

^  Jones,  "  Injuries  to  Joints, "  Oxford  War  Primer,  1918. 
39 


610 


INDUSTRIAL    MEDICINE    AND    SURGERY 


axilla  and  to  which  a  single  forearm  splint  was  fixed  by  a  hinged 
piece  of  strap  iron.     Continuous  extension  was  maintained  by  a  bag 


Fig.   145. — Wood  triangle  splint  ueed  in  French  army  hospitals. 

of  sand  suspended  from  the  humerus  or  forearm  when  extension  was 
necessary.  The  results  with  this  simple  apparatus  were  excellent  (Fig. 
145). 


Fig.   146. — Delbet  arm  extension  apparatus.      {Techniques  des  Operations  et  Pansements 
Plates  de  Guerre,  D""  Dupuy  c?e  Frenelle,  Aide-maj or-V I"  armee.) 

Among  the  more  recent  appliances  is  the  Delbet  apparatus  for 
continuous  extension.     In  this  splint  the  force  of  extension  is  adjusted 


FRACTURES 


611 


by  a  movable  pin  as  seen  in  cut.  The  method  of  application  is  well 
shown  (Fig.  146). 

"An  excellent  splint  for  fractures  of  the  humerus  and  one  adopted  by 
the  United  States  Army  is  the  Jones  elbow  extension  splint.  This 
splint  may  be  used  for  continuous  extension  of  either  the  humerus 
or  forearm  (Figs.  147  and  148). 

"There  are  two  methods  of  applying  traction  to  the  humerus;  first, 
by  the  Hennequin  band,  second,  by  glued  traction  bands.     The  Hen- 


FiG.  147.  Fig.   148. 

Figs.   147  and  148. — Jones   arm   extension  splint.      Method  of  application.     {Injuries 
to  Joints,  Second  Edition,  Oxford  War  Primers.) 

nequin  band  is  a  band  made  of  Canton  flannel,  four  inches  wide  and 
eighteen  inches  long.  It  is  appHed  over  several  thicknesses  of  non- 
absorbent  cotton  wound  snugly  about  the  lower  part  of  the  arm  just 
above  the  elbow.  Over  this  pad  the  band  is  applied  from  behind 
forward,  crossed  in  front  and  pinned  at  the  sides  so  that  there  is  a 
direct  pull  along  the  arm. 

"The  glued  traction  bands  are  also  made  of  flannel  of  shape  similar 
to  cut  (Fig.  149). 


612 


INDUSTRIAL    MEDICINE    AND    SURGERY 


^/^ 


es 


ho//?  yS^me  pc9/^fn 


"The  glue  with  which  these  bands  are  applied  is  made  as  follows: 
"Resin  and  Turpentine  Glue:^ 

Resin 50 

Alcohol. 50 

•  Benzine  (pure) 25 

Venice  turpentine 5 

"Powder  the  resin,  then  add  half  the  alcohol,  then  the  Venice 
turpentine  and  benzine,  washing  the  measure 
into  the  bottle  with  the  remaining  alcohol. 
This  glue  may  be  removed  with  alcohol  or 
ether.  The  bottle  containing  the  glue  should 
be  kept  tightly  stoppered  else  the  proportions 
of  the  constituents  may  change,  and  the  glue 
become  irritating  to  the  skin.  This  glue  does 
not  require  heating  before  use,  and  should 
not  be  applied  too  thickly. 

"Moderate  traction  may  be  safely  insti- 
tuted with  this  form  of  glue  in  from  5  to  10 
minutes  after  application,  and  as  much  trac- 
tion as  is  required  in  20  minutes. 

"Fractures  About  the  Elbow-joint. — Jones 
makes  the  following  statement  which  should 
always  be  remembered: 

"  'There  is  one  golden  rule  regarding  frac- 
tures of  the  elbow :  they  should  all  be  treated 
with  the  elbow  fully  flexed  and  the  forearm 
supinated,  with  the  single  exception  of  fracture 
of  the  olecranon,  which  requires  full  extension.' 

"The  method  of  putting  up  an  elbow  in 
acute  flexion  is  shown  in  Fig.  150. 

"After  a  few  days,  four  or  five,  it  is  safe  to 
relax  the  acuteness  of  the  flexion  and  shng  the 
wrist  of  the  affected  arm  close  under  the 
chin.  The  shng  may  be  lengthened  from  day 
to  day,  and  the  patient  urged  to  try  active 
motion.  War  surgery  has  developed  the 
fact  that  in  injury  to  the  joints  active  mo- 
tion should  be  started  at  the  earliest 
possible  date,  but  this  motion  should  be  done  at  first  under  the  careful 
supervision  of  the  surgeon  and  if  any  stiffness  or  severe  sweUing 
appears  as  a  result,  acute  flexion  should  be  resumed  for  a  few  days. 

1  Formula  from   Manual  of  Splints  and   Appliances,    Medical    Department, 
U.  S.  Army. 


Fig.  149. — Flannel  band 
for  traction.  To  be  applied 
to  skin  witb  special  glue 
painted  on  with  paint 
brush. 


FRACTURES  613 

"Fractures  of  Forearm. — Fracture  of  both  bones  of  the  forearm 
are  notoriously  difficult  to  reduce  and  hold  in  position.  There  appears 
to  be  nothing  especially  new  in  the  treatment  developed  by  war  except 
in  the  case  of  compound  fractures  of  the  forearm. 

"A  double  board  splint  with  imm9bilization  of  the  elbow  by  a  tin 
right  angle  splint,  as  described  by  Scudder,  or  the  moulded  anterio- 
posterior plaster  splints,  described  by  Moorhead,  are  prObably  the 
best  methods  of  holding  after  reduction  by  traction  and  manipulation. 


Fig.  150. — Elbow  put  up  in  acute  flexion.  Forearm  supinated  and  elbow  in 
flexion.  Note  heavy  padding  on  arm  and  forearm,  as  well  as  protective  padding  in 
inner  side  of  arm  and  forearm  where  this  comes  in  contact  with  chest. 

"The  French  use  forms  of  crinohne  to  make  their  molded  splints. 
These  forms  consist  of  ten  thicknesses  of  crinoline  basted  together. 
The  forms  are  immersed  in  plaster  bouillon  immediately  before  using 
with  vasehn.  The  method  of  making  the  plaster  bouillon  is  given 
under  the  treatment  of  fracture  of  the  thigh  and  with  description  of 
the  Delbet  plaster  forms. 

"This  method  of  application  of  plaster  is  rapid,  accurate  and  the 
form  can  be  cut  to  suit  the  case  and  surgeon.  After  appHcation  it  is 
held  in  place  by  a  gauze  bandage  until  the  plaster  sets. 


614 


INDUSTRIAL    MEDICINE    AND    SURGERY 


"So  much  has  been  written  on  the  reduction  and  retention  of  Colles' 
fracture  that  it  seems  unnecessary  to  repeat  what  is  already  known. 

"There  are  two  points  which  are  worth  bearing  in  mind.  First, 
complete  reduction  has  not  been  obtained  until  the  styloid  process  of 
the  radius  is  well  below  the  stj^oid  process  of  the  ulna.  Second,  the 
tearing  of  the  internal  lateral  ligament  of  the  wrist  is  frequently  more 
troublesonie  than  the  fracture  of  the  radius. 


Fig.  151. 

"After  reduction  both  anterior  and  posterior  sphnts  should  be  kept 
in  place,  except  during  massage,  for  three  weeks,  and  the  anterior 
splint  for  one  week  longer   (Figs.   151  and  152). 

"Fractures  of  the  carpal  bones  are  very  troublesome  and  give  rise 
to  considerable  disability  in  the  wrist.  It  is  almost  impossible  to  ap- 
pose the  fragments  and  in  order  to  get  a  useful  wrist  the  open  opera- 
tion is  often  necessary.  This  is  particularly  true  in  fracture  of  the 
scaphoid. 


Fig.  152. 

Figs.   151  and  152. — Jones  cock-up  wrist  splint.      For  use  in  injuries  where  dorsal  flexion 

of  the  wrist  is  advisable.      (Injuries  to  Joints,  Second  Edition,  Oxford  War  Primers:) 

"Fractures  of  the  metacarpals  are  fairly  common.  Reduction  is 
difficult  but  should  always  be  attempted.  It  is  more  likely  to  succeed 
if  a  general  anesthetic  is  given  and  the  position  of  the  fragments 
checked  up  with  a  fluoroscope  during  reduction.  The  reduction 
can  usually  be  well  held  if  the  hand  is  strapped  over  a  roller  bandage, 
the  principle  being  the  same  as  that  of  acute  flexion  in  the  elbow.  Ex- 
tension by  means  of  traction  on  the  finger  of  the  injured  metacarpal 
is  rarely  successful  and  is  difficult  to  manage. 

"In  industrial  surgery  fractures  of  the  fingers  and  thumb  are  most 


FRACTURES  615 

important  and  much  of  the  worker's  skill  may  be  lost  by  a  poor  result. 
The  greatest  care  should  be  used  in  setting  these  fractures  and  after 
reduction  the  result  should  be  checked  up  by  an  a;-ray  picture.  The 
wooden  tongue  depressor  splint  is  clumsy  and  inefficient  except  as  a 
first  aid  dressing. 

"The  best  method  of  retention  is  probably  the  Marsee  block  tin 
r- —  .  -  . 


Fig.   153. — Marsee's  tin  finger  splint. 

finger  splint  made  as  follows :  A  strip  of  tin  is  cut  14  in.  long  and  23^^ 
in.  wide.  This  is  to  be  folded  upon  itself  lengthwise  and  hammered 
flat  so  as  to  make  a  three-ply  strip  ^  in.  in  width.  Upon  one  end  of 
the  strip,  a  piece  of  thin  leather  or  canvas  4  or  5  in.  long  and  3  in.  wide 
is  to  be  riveted  in  order  to  give  the  strip  stability  when  bandaged  to 


Fig.   154. — Method  of  application  of  Marsee's  finger  splint  before  bandage  is  applied. 
Note  natural  curve  of  finger. 

the  forearm.  The  strip  is  then  shaped  to  suit  the  curved  outline,  in 
which  position  the  fingers  should  be  immobilized  (Figs.  153  and  154).^ 
"By  means  of  this  spKnt  anterior  bowing  can  be  overcome  and  sad- 
dle-shaped deformity  controlled.  For  fractures  with  Httle  displace- 
ment there  is  nothing  better  than  a  strong  hair  pin  which  when  wound 
^Sluss,  "Emergency  Surgery,"  Third  Edition. 


616  INDUSTRIAL    MEDICINE    AND    SURGERY 

with  adhesive  plaster  makes  a  light  and  easily  adaptable  splint.  An- 
terior and  posterior  hair  pin  spHnts  hold  the  fracture  well  with  a  mini- 
mum of  bulk  and  weight. 

"For  crushes  of  the  terminal  phalanx  no  splint  is  required  but  great 
comfort  is  obtained  if  the  Manning  tin  cross  piece  is  applied  over  the 
dressing.  These  have  been  used  in  many  factory  dispensaries  with 
universal  success  and  no  industrial  surgeon  should  be  without  at  least 
a  dozen  always  on  hand. 

Fractures  of  the  Lower  Extremity 

"Fractures  of  Femur. — Fractures  of  the  neck  of  the  femur  are  di- 
vided into  impacted  and  non-impacted  fractures.  If  there  is  firm  im- 
paction with  httle  shortening,  httle  need  be  done  beyond  sand  bags 
to  steady  the  leg  and  hght  traction  by  weight  and  pulley,  or  better  sus- 
pension in  a  Balkan  frame.  A  description  of  this  method  of  handling 
fractures  of  the  femur  will  follow. 

"Whitman  beheves  in  breaking  up  the  impaction  under  anesthesia 
and  setting  the  leg  in  wide  abduction  with  some  internal  rotation 
holding  the  position  with  a  plaster  cast  extending  from  the  toes  to  the 
axilla.  "The  Kmb  is  reduced  by  extension  and  gradual  abduction  to 
an  angle  of  forty-five  degrees,  in  the  meantime  supporting  the  upper 
end  of  the  femur  and  rotating  the  leg  inward. 

"In  this  position,  the  limb  is  well  covered  with  cotton  batting,  all  the 
bony  points  especially  well  protected  and  a  flannel  bandage  smoothly 
applied.  A  plaster  spica  is  now  applied  extending  from  the  lower 
ribs  to  and  including  the  foot.  The  plaster  fits  the  pelvis  snugly  and 
is  molded  close  to  the  trochanter  and  posterior  aspect  of  the  joint. 
It  is  also  molded  to  the  patella  and  condyles,  and  to  the  foot  to  pre- 
vent rotation.  This  dressing  permits  the  patient  to  rise  up  in  bed 
without  much  discomfort. 

"The  advantage  of  abduction  is  that  it  makes  the  capsule  tense  and 
thus  ahgns  the  displaced  fragments,  that  it  directs  the  surface  of  the 
outer  fragment  toward  that  of  the  inner;  that  it  relaxes  the  muscles 
that  produce  distortion  by  their  traction;  that  it  opposes  the  trochan- 
ter to  the  side  of  the  pelvis  and  thus  checks  upward  displacement. 
Repair  in  these  fractures  is  slow  and  can  hardly  be  completed  with- 
in a  year;  thus  prolonged  after-treatment  is  necessary  for  restoration 
of  function.  ^ 

"In  cases  of  non-impaction  three  methods  are  open  to  the  surgeon: 
first,  the  Whitman  method  as  outHned  above;  second,  suspension  and. 
traction  in  a  Balkan  frame  and  Thomas  sphnt;  third,  open  reduction 
and  nailing  the  fragments  in  alinement.  Jones  has  developed  a  frame 
which  holds  the  femur  in  abduction,  altows  traction  and  affords  an 

1  Jour.  Am.  Med.  Assoc,  February  20,  1909  (Sluss). 


FRACTURES 


617 


easy  means  of  transport.     It  is  of  particular  value  in  the  case  of 
compound  fractures  (Fig.  155). 

"In  war  hospitals  all  thigh  and  many  leg  fractures  are  being  treated 
by  means  of  the  Balkan  frame,  suspension  and  traction.  This  method, 
now  almost  unknown  in  civil  surgery,  will  probably  be  largely  used 
after  the  war.  The  Balkan  frame  consists  of  a  head  frame  and  a  foot 
frame  of  wood  united  by  longitudinal  bars.  The  wood  is  white  pine,  % 
by  2  inches.  The  head  and  foot  frames  consist  of  two  uprights  slightly 
slanted  to  form  a  truncated  A.     The  cross  bars  which  hold  these 


Fig.   155.- 


-Jones  abduction  frame  for  high  fractures  of  the  femur. 
Second  Edition,  Oxford  War  Primers.) 


{Injuries  to  Joints, 


uprights  together  are  the  width  of  the  bed,  at  top  extending  beyond 
uprights  on  either  side,  while  the  lower  joins  the  uprights  at  the  level 
of  the  mattress. 

"The  longitudinal  bars  are  two  in  number,  resting  on  the  upper 
cross  bars  and  retained  in  any  desired  position  by  reciprocal  notches 
(mortise  joint). 

"The  exact  measurements  are  as  follows:  height  of  side  bars,  head 
and  foot  frame,  6  ft.  6  in.;  length  of  upper  notched  transverse  bar, 
3  ft.  3  in.;  length  of  lower  transverse  bar,  width  of  bed  at  top  of  mattress; 
length  of  longitudinal  frame  connecting  bars,  8  ft.  8  in. 

"The  head  and  foot  frames  are  set  up  and  attached  to  the  bed 
with  rope;  they  are  then  joined  by  the  two  longitudinal  bars  which 
lock  by  their  reciprocal  notches  in  the  upper  cross  piece  of  the  head 


618 


INDUSTRIAL    MEDICINE    AND    SURGERY 


and  foot  frames,  making  the  whole  frame  firm  and  rigid.  One  of 
these  bars  can  be  brought  out  at  an  angle  so  as  to  produce  abduction 
and  additional  cross  bars  of  varying  width  can  be  added  to  the  foot 
frame  for  the  support  of  pulleys.  The  Thomas  or  Hodgen  sphnt 
(Fig.  156)  is  suspended  from  three  pulleys  set  in  a  block  of  wood  16 
inches  long  which  in  turn  is  supported  by  the  longitudinal  bar.  The 
set-up  frame  and  arrangement  of  pulleys  is  well  shown  in  the  accom- 
panying cuts  from  the  Red  Cross  Splint  Manual  of  the  United  States 
Army. 

"The  method  of  apphcation  is  as  follows:  The  frame  having  been 
set  up  with  all  bars  arranged  for  the  proper  amount  of  abduction  and 
the  pulleys  having  been  placed,  the  Hodgen  or  Thomas  splint  is  pre- 


.^a=^ 


Fig.  156. — Balkan  frame.  Suspension  method  of  treatment  of  fractured  femur. 
Note  method  of  obtaining  abduction  by  additional  bars  on  frame;  to  compare  with 
figure  of  Hodgen  splint.  (Manual  of  Splints  and  Appliances  for  the  Medical  Department 
of  the  United  States  Army,  1917.) 


pared  as  shown  in  the  photograph.  The  sphnt  is  then  attached  by 
cords  to  the  three-pulley  block.  Glued  bands  are  now  applied  to  the 
leg  which  has  been  previously  shaved  and  washed  with  alcohol  and 
ether.  The  glued  bands  extend  a  little  above  the  site  of  the  fracture  as 
their  pull  is  exerted  through  the  skin  and  fascia  lata  before  reaching 
the  muscles  and  bone  (Figs.  157  and  158). 

"The  splint  is  now  dropped  over  the  leg  and  the  shngs  brought 
under  the  thigh  and  leg  and  fixed  to  the  outer  bar  of  the  sphnt  with 
paper  chps,  usually  more  slings  are  used  than  are  shown  in  the  cut. 


FRACTURES 


619 


The  whole  leg  is  then  gently  raised  and  the  suspension  weight  adjusted. 
This  should  exactly  equal  the  weight  of  the  leg  and  splint.  Sand  or 
buck  shot  may  be  used  in  the  weight  bag.  A  second  cord  with  about 
four  pounds  of  weight  passes  from  the  upper  end  of  the  splint  over  a 


Fig.  157. — Hodgen  sjplint. 

pulley  set  at  the  opposite  side  of  the  head  of  the  bed.     This  acts  as  a 
countertractor. 

"The  extension  bands  are  now  attached  to  a  spreader  and  the  proper 
amount  of  weight  attached  to  the  rope  after  it  has  passed  through  the 


Fig.  158.— Method  of  suspension  with  Hodgen  splint  in  Balkan  frame,  a,  Slings 
which  hold  in  splint,  held  in  place  by  paper  clips;  h,  foot  piece  of  flannel  glued  to  foot; 
c,  hand  grips  so  that  the  patient  may  help  raise  and  lower  himself  in  bed;  W,  weight; 
H,  pulley  hooks.  {Manual  of  Splints  and  Appliances  for  the  Medical  Department  of  the 
United  States  Army,  1917.) 


pulley.  Last  of  all  a  flannel  band  is  cut  the  shape  of  the  sole  of  the  foot 
and  glued  in  place.  The  tape  is  tied  to  a  piece  of  cord  which  is  carried 
over  the  middle  block  pulley  and  to  which  a  one-pound  weight  is 


620 


INDUSTRIAL    MEDICINE    AND    SURGERY 


attached.     This  allows  free  movement  of  the  ankle,  exercise  of  the 
muscles  of  the  leg  and  prevents  foot  drop  (Fig.  159). 

"The  advantage  of  the  suspension  method  of  treating  fractures  is 
as  follows : 

"l.  There  is  no  pain. 

"2.  There  is  no  edema. 

"3.  There  is  no   motion  of  all  the  joints  without  displacement 

of  the  alignment  of  the  fragments. 
"4.  The  patient  can  move  around  in  bed. 
"5.  The  leg  may  be  easily  examined  and  massaged. 

"It  will  be  noted  that  this  method  of  treatment  completely  upsets 
the  time  honored  belief  that  a  fracture  must  always  be  treated  by  a 


Fig.   159. — Application  of   Thomas  splint  for   suspension   and   traction.      (Manual  of 
Splints  and  Appliances  for  the  Medical  Department  of  the  United  States  Army,  1917.) 

sphnt  which  immobihzes  the  joints  above  and  below  the  site  of  injury. 
Where  considerable  traction  is  needed,  two  sets  of  glued  bands  can 
be  used,  one  attached  to  the  thigh  as  described  above,  a  second  pair 
attached  to  the  leg.  To  each  of  these  traction  weights  are  apphed. 
When  the  traction  is  so  great  that  it  tends  to  pull  the  patient  down  in 
the  bed,  the  foot  of  the  bed  may  be  elevated  on  blocks. 

"When  much  traction  is  needed,  the  Steinman  pin,  'ice  tongs,' 
or  the  Finechette  stirrup  may  be  used.  In  the  case  of  the  pin  much 
less  traction  weight  is  needed  than  when  the  glued  bands  are  used. 
Blake  recommends  the  use  of  the  Steinman  pin  in  all  cases  of  fracture 
just  above  the  knee  joint. 


TRACTURES 


621 


"In  a  resume  such  as  this  it  is  impossible  to  go  into  the  necessary- 
details.  For  a  full  and  detailed  account  the  reader  is  referred  to  the 
excellent  paper  by  Blake  in  La  Presse  Medicale,  November  19,  1917. 

"Fractures  of  the  middle  of  the  femur  can  be  treated  in  two  ways: 
first,  by  the  suspension  and  traction  method  just  described;  second, 
by  plaster  cast  extending  from  the  toes  to  the  chest.  If  a  plaster  cast 
is  used,  proper  reduction  can  best  be  secured  by  the  use  of  the  Hawley 
table  or  similar  apparatus  for  producing  mechanical  traction.  Where 
the  Hawley  table  is  not  available,  and  it  is  considered  advisable  to 
use  plaster,  the  following  method  may  be  used.     This  is  the  method 


Fig.  160. — Type  of  fracture  bed  used  in  Colorado  Fuel  &  Iron  Co.  Hospital.     {Clinic 

of  Dr.  Corwin.) 

which  is  now  in  use  in  a  great  many  hospitals  in  France  where  expense 
prevents  their  having  up-to-date  tables  and  apparatus. 

"The  patient  is  supported  on  an  ordinary  table  by  a  box  under  the 
shoulders  and  chest,  while  the  pelvis  is  supported  by  a  tin  can  or  a 
couple  of  bricks  under  the  sacrum.  The  affected  leg  is  extended  by- 
means  of  a  clove-hitch  of  wide  bandage  which  is  appUed  over  several 
layers  of  cotton  wound  around  the  ankle.  The  ends  of  the  muslin 
bandage  used  in  making  the  clove-hitch  are  carried  over  a  tin  can  or 
bottle,  and  then  over  the  end  of  the  table.  To  the  bandage  ends  a 
bucket  is  attached  which  can  be  filled  with  water  or  sand  to  produce 
traction.     Countertraction  is  obtained  by  a  loop  of  pillow  case  or 


622  INDUSTRIAL   MEDICINE    AND    SURGERY 

sheet  which  passes  under  the  crotch  and  is  attached  to  a  rope  or  to  the 
leg  of  the  table  near  the  patient's  head.  This  method  is  well  described 
by  Calot  in  his  recent  'Orthopedic  et  Chirurgie  de  Guerre,'  third 
edition.  Calot  describes  the  apphcation  of  a  plaster  case  for  fracture 
of  the  femur  about  as  follows.  I  have  not  used  his  words  but  have 
abbreviated  to  make  the  matter  more  condensed. 

"Two  types  of  plaster  appHances  are  used.  First,  five  plaster  band- 
ages 3  or  4  inches  wide,  and  second,  four  atteles,  oblong  strips  of 
crinoline,  five  thicknesses  each,  two  cut  long  enough  to  extend  from  the 
toes  to  the  hip,  both  in  front  and  behind,  and  wide  enough  to  slightly 
overlap  when  wrapped  around  the  leg,  one  wide  enough  to  extend  from 
pubis  to  sternum  and  long  enough  to  surround  the  abdomen,  and  a 
fourth  about  four  inches  in  width  and  long  enough  to  encircle  the  hip 
obliquely.  The  method  of  application  is  as  follows :  After  the  patient 
has  been  placed  in  the  proper  position  and  traction  apphed,  the  leg 
and  abdomen  are  completely  enveloped  in  one  thickness  of  sheet 
wadding,  stockingette  or  ordinary  drawers,  extending  from  the  toes  to 
the  ribs.  Two  bandages  are  then  dropped  in  cold  water  in  a  large 
basin  holding  three  quarts  without  salt.  About  three  minutes  later 
three  other  bandages  are  dropped  into  this  water.  As  soon  as  possible 
the  first  bandages  are  wrung  out  and  handed  to  the  surgeon  who  appHes 
them  from  the  toes  to  the  hip  in  the  usual  manner.  While  this  is  being 
done,  another  basin  of  plaster  bouillon  is  being  prepared  by  an  assistant. 
This  plaster  bouillon  which  is  used  very  widely  by  the  French  in  the 
use  of  their  plaster  forms  of  various  types  is  made  as  follows : 

"Three  glasses  of  water  are  poured  into  a  basin  to  which  is  added 
rapidly  five  glasses  of  plaster,  the  plaster  being  shaken  in  httle  by 
little  rapidly  while  the  left  hand  of  the  operator  agitates  the  water  to 
obtain  an  homogeneous  bouillon.  This  should  be  obtained  in  about 
one  minute. 

"The  atteles  of  crinoline  are  then  plunged  into  the  bouillon  and 
worked  through  it  rapidly  absorbing  the  mixture.  These  are  then 
appHed  to  the  anterior  and  posterior  of  the  leg  extending  from  the  toes 
to  the  groin.  Immediately  following  this  apphcation,  another  attele 
is  apphed  around  the  pelvis  and  abdomen.  This  attele  has  been  cut 
wide  enough  to  extend  from  the.  pelvis  to  the  base  of  the  chest  and 
forms  a  broad  belt  around  the  abdomen  and  pelvis.  The  ends  overlap 
in  the  region  of  the  groin.  The  fourth  attele  is  next  prepared  and  is 
applied  over  this.  This  attele  consists  of  a  band  about  4  inches  wide, 
five  thicknesses  of  crinohne,  which  is  long  enough  to  completely  en- 
circle the  hip  and  extends  up  over  the  groin.  The  exact  method  of 
the  arrangement  of  these  atteles  appears  in  the  accompanying  cut. 
Immediately  after  having  apphed  these  atteles,  the  three  remaining 
plaster  bandages  are  apphed  from  the  toes  well  up  to  the  base  of  the 
chest,  completing  the  cast.     It  is  well  after  putting  on  the  atteles  to 


FRACTURES 


623 


cover  them  with  a  thick  layer  of  plaster  bouillon  taken  from  one  of  the 
basins  in  which  the  atteles  have  been  prepared,  and  after  the  last 
plaster  bandage  is  applied,  the  whole  cast  may  be  gone  over  with  this 
same  material.  The  application  of  such  a  cast  requires  assistants  in 
order  to  achieve  it  quickly.  Calot  states  that  the  entire  application 
can  be  done  in  five  to  six  minutes,  or  eight  at  the  most.  He  advocates 
practice  in  team  work  between  the  nurses  and  the  doctor.  Immedi- 
ately after  the  cast  has  been  applied,  it  should  be  carefully  moulded  in 
the  region  of  the  knee,  ankle  and  the  crest  of  the  ihum.  This  point 
is  most  important  and  has  been  brought  out  not  only  by  Calot  but  by 
Whitman.  Great  care  should  be  taken  that  the  foot  is  at  right  angles 
to  the  leg  and  slightly  inverted.     Such  a  cast  can  be  readily  split  if  it 


Fig.  161. 


-Application  of   cast  as  described   by   Calot  and   used  in  the   French  war 
hospitals. 


appears  to  be  too  tight.  If  it  is  probable  that  such  sphtting  will  be 
necessary,  a  long  piece  of  tin  can  be  incorporated  beneath  the  sheet 
wadding  so  that  the  knife  will  have  a  firm  base  to  cut  upon,  and  there 
is  no  danger  of  injuring  the  patient  (Fig.  161). 

"Fractures  of  the  Leg. — Fractures  of  both  bones  of  the  leg  can  be 
treated  either  by  suspension  and  traction,  or  by  plaster  cast.  The 
cast  in  this  case  does  not  have  to  be  as  heavy  as  that  described  for  the 
thigh  fractures,  but  should  extend  from  the  toes  well  above  the  knee. 
Particular  care  should  be  taken  that  there  is  no  anteriorposterior 
bowing.  After  a  fracture  has  become  consolidated,  if  the  callous  is 
still  soft,  the  French  are  accustomed  to  apply  a  Delbet  plaster  appareil 
de  marche.  The  French  also  use  this  method  of  treatment  for  simple 
fractures  of  the  fibula  and  for  Pott's  fracture  after  reduction.     The 


624 


INDUSTRIAL    MEDICINE    AND    SURGERY 


patient  is  able  to  hobble  around  on  this  splint,  and  it  apparently  causes 
no  bending  or  weakening  of  the  callous.  It  will  be  seen  that  the 
weight  of  the  leg  is  borne  largely  on  the  lateral  and  longitudinal  atteles, 
and  that  the  bone  is  still  further  protected  by  the  bands  around  the 
ankle  and  below  the  knee  which  prevent  strain  upon  the  callous  by 
transmitting  the  weight  to  these  same  lateral  atteles.     The  atteles  are 


DELBET     FORMS 

(CRINOLINE.) 
OupplcmcntsJ  To  dcscriptiorvTurnisned  py  Dr.  W' Ir-ving  Cl&rly  To 
Xn«  CTonTarcnca  Bo^rd  oi  Pnysicie-n^  in  Inouslriivl    r^ractice    tkl  jfa   mficiing  Ju 


g  June  29.    1918 


(?.»-) 


<3:„0 


to™) 


(z™-; 


l6   thickne 


22  tdickr 


(?5i  ■■'■=■■> 


^(4   iB.J 


22  iklcL 


l6  tliickne 


^^Lrxi 


4  oelowncel' 


Fold  back. 


Grips  Lad  of  fitula  anj 
iubarosity  of  Jitia- 


J.  inta 


ripscxtenop.and.  inwripr 
rnalleoli. 

Fbld  back.. 


Fig.  162. — -Diagrammatic  description  of  Del  bet  forms.    {Dr.  W.  Irving  Clark.) 


made  of  crinoline,  as  indicated  in  the  cut,  and  are  prepared  by  being 
rolled  through  plaster  bouillon  (Fig.  162). 

"This  plaster  bouillon,  which  as  I  said  before  is  greatly  used  by 
the  French,  is  usually  made  as  follows : 

"The  basin  is  filled  with  about  a  quart  of  cold  water.  To  this  is 
added  plaster  little  by  little,  the  plaster  being  shaken  in  while  the 


FRACTURES  625 

water  is  being  gently  agitated  by  the  left  hand  of  the  surgeon.  When 
the  withdrawn  hand  appears  as  if  it  was  covered  with  a  thick  white 
cotton  glove,  the  proper  consistency  has  been  reached. 

"The  trick  of  preparing  a  proper  bouillon  is  one  which  requires 
a  little  practice,  but  when  it  has  been  acquired  the  surgeon  will  find 
his  ability  to  handle  certain  types  of  fractures  greatly  increased. 

"Simple  fractures  in  the  region  of  the  ankle,  such  as  Pott's  fracture, 
can  probably  be  best  treated  by  reduction  in  a  classical  manner,  and  a 
plaster  cast,  the  foot  being  held  in  exaggerated  inversion.  After 
about  a  week,  Delbet's  appareil  may  be  tried  if  the  swelling  is  not  too 
severe. 

"The  French  frequently  apply  the  Delbet  even  on  complete  fracture 
of  both  bones,  making  traction  by  means  of  a  weight  over  a  tin  can,  as 
described  before.  When  reduction  has  been  obtained  the  Delbet 
forms  are  apphed  and  held  in  place  by  a  Scultetus,  many-tailed  bandage 
which  remains  on  for  twenty-four  hours.  The  traction  is  of  course 
removed  as  soon  as  the  plaster  has  set.  The  patient  should  be  able 
to  walk  with  the  Delbet  and  a  cane  the  day  following  the  application 
of  the  splint.  An  important  point  which  is  sometimes  neglected  in  the 
after  treatment  of  cases  of  Pott's  fracture  is  the  necessity  of  keeping 
the  foot  in  inversion,  and  supporting  the  arch  with  a  pad,  or  flat-foot 
plate.  Every  case  of  Pott's  fracture,  or  of  fracture  of  the  ankle, 
excepting  the  phalanges,  should  be  supported  by  a  firm  foot  pad  and 
adhesive  plaster  strapping  when  the  patient  is  up  and  around. 

"Compound  Fractures. — The  treatment  of  compound  fractures 
is  exactly  the  same  as  that  of  simple  fractures  with  the  exception 
of  the  treatment  of  the  wound.  The  treatment  of  the  wound  consists 
of  the  primary  treatment  and  the  secondary,  or  operative  treatment. 
The  primary  treatment  which  occurs  immediately  after  the  injury 
should  consist  of  painting  the  wound  rapidly  with  tincture  of  iodin, 
and  applying  a  sterile  dressing  consisting  of  many  folds  of  gauze  in 
the  form  of  a  thick  pad,  held  in  place  by  a  bandage.  The  operative 
treatment  is  the  same  as  is  now  used  in  the  war  hospitals  of  France. 
This  consists  of  a  careful  dissection  of  all  of  the  injured  tissues,  a  knife 
being  used  to  cut  out  the  skin  in  a  fine  elliptical  incision.  Where  there 
is  some  question  as  to  whether  the  tissue  is  viable  or  not,  no  chances 
should  be  taken,  but  the  tissue  unless  of  great  value  should  be  removed. 
In  short,  the  entire  wound  tract  should  be  treated  as  if  it  were  a  new 
growth,  and  removed  enbloc  if  possible. 

"The  following  quotation  from  Major  Poole  is  an  exact  description 
of  the  methods  now  being  employed  in  the  treatment  of  compound 
fractures,  caused  by  accidents,  at  La  Panne,  and  should  act  as  a  guide 
in  the  treatment  of  compound  fractures  in  industrial  work: 

"  'These  are  operated  upon  as  routine  at  La  Panne  and  when  it  is 

40 


626 


INDUSTRIAL   MEDICINE    AND    SURGERY 


possible  the  following  procedure  is  followed :  The  edges  of  the  wound 
are  excised,  contaminated  or  lacerated  tissues  are  carefully  excised, 
the  fracture  is  exposed  and  as  far  as  possible  the  fragments  are  reduced. 
Foreign  bodies  such  as  plates,  screws  and  wires  are  not  employed  except 
in  rare  cases  for  the  reason  already  given  under  "Treatment  of  Com- 
pound Fractures '  caused  by  Projectiles."  The  wound  is  closed  by 
layers  without  drainage.'^ 

"It  is  evident  that  the  chance  of  infection  is  less  in  industrial  work, 
and  wherever  possible  the  tissue  should  be  saved  and  not  sacrificed. 
With  the  facilities  for  prompt  treatment,  it  would  seem  possible 
to  convert  the  majority  of  compound  fractures  into  simple  fractures  by 


Fig.  163. — Treatment  of  an  infected   compound   fracture  by  Carrel-Dakin  irrigation 
method.     Inserting  the  tubes.      {Dr.  Corwin.) 

primary  suture.  Any  loose  bone  which  is  apparently  free  of 
periosteum  should  be  removed  but  care  should  be  taken  to  leave  in 
place  all  bits  of  bone  to  which  the  periosteum  is  adherent.  In  cases 
where  there  is  much  contamination,  especially  where  this  extends 
to  the  bone,  it  is  better  to  follow  the  tactics  of  war  surgery  and  not 
attempt  primary  suture.  It  should  be  noted  here  that  owing  to  the 
dangers  of  special  infection  and  lack  of  immediate  treatment,  the 
French  do  not  dare  to  practice  primary  suture  in  compound  fractures, 
except  in  very  special  cases.  After  the  wound  has  been  treated,  the 
fracture  should  be  treated  by  one  of  the  methods  outlined  in  the  treat- 
ment of  simple  fractures.  However,  the  use  of  plaster  is  contra- 
1  Poole,  Surg.  Gyn.  and  Obs.,  Sept.,  1918. 


FEACTURES  627 

indicated  where  one  expects  to  have  to  deal  with  a  suppurating  wound, 
and  if  this  condition  is  considered  probable,  the  suspension  method 
of  treatment  should  be  adopted. 

"Infection  in  a  compound  fracture  is  a  common  occurrence  in 
France,  and  the  usual  method  of  combating  it  is  by  the  use  of  the 
Carrel-Dakin  method.  This  has  been  so  fully  described  that  the 
technic  will  not  be  entered  into  here.  It  may  be  of  interest  to  note 
that  by  the  Carrel  method  other  solutions  than  Dakin's  are  used. 
Those  which  have  proved  most  successful  in  the  American  Red  Cross 
Military  Hospital  No.  2  are  appended.  For  further  information 
as  to  the   method  of  suspension  treatment  of  compound  fractures, 


Fig.   164. — Compound  fracture  of  leg  due  to  industrial  injury  treated  by  Carrel-Dakin 

method.      {Dr.  Corwin.) 

the  reader  is  referred  to  Major  Blake's  paper  in  La  Presse  Medicale, 
November  19,  1917." 

Dressing  Solution  Formulas. — American  Red  Cross  Military  Hospital  No  2, 
Paris. 

Dressing  solution  for  fresh  wounds: 

1.  Quinin  hydrochlorid 1 

Acetic  acid  (90%) 5 

NaCl 8 

H2O 1000 

2.  Acetic  acid 5 

NaCl 8 

H2O 1000 


628  INDUSTRIAL   MEDICINE    AND    SURGERY 

Dressing  solutions  for  granulating  wounds : 

3.  B.  Naphthol 1 

Sod.  hvdrox 1 

H,0.;. • ■  1000 

4.  Daufresne's  modification  of  Dakin's  solution. 

5.  Sodium  bicarb lO 

NaCl : 8 

H,0 1000 


CHAPTER  XXXVIII 
OPEN  TREATMENT  OF  FRACTURES 

The  growing  tendency  among  surgeons  to  operate  upon  many  cases 
of  fracture  which  hitherto  gave  good  functional  results  by  the  closed 
method  of  treatment  makes  it  seem  timely  to  illustrate  many  of  the 
bad  results  which  occur  by  open  treatment.  The  various  figures  rep- 
resent cases  collected  in  one  of  our  best  hospitals  and  the  operations 
were  performed  by  surgeons  with  the  best  of  reputations. 

Cases  of  recent  fractures  and  many  cases  of  old  fractures,  bony 
defects,  bone  cysts,  etc.,  do  arise,  however,  in  which  open  operative 
treatment  is  surely  indicated.  The  purpose  of  this  chapter,  there- 
fore, is  not  to  condemn  such  operations  but  rather  to  stimulate  a  more 
conservative  attitude  toward  selecting  the  types  of  fractures  so  treated 
and  the  methods  employed. 

The  bone  graft  has  become  a  fixture  in  surgery.  A  great  amount 
of  experimental  work  on  animals  has  been  reported  and  has  made  pos- 
sible the  advances  in  this  branch  of  surgery.  However,  it  is  only  by 
the  reporting  of  many  and  various  results  on  humans  by  the  rank  and 
file  of  surgeons  that  the  indications  and  technic  of  this  operation  will 
become  fully  established,  and,  above  all,  that  the  autogenous  bone  graft 
will  become  recognized  as  the  safest  and  surest  method  of  repairing  cer- 
tain bony  defects — far  superior,  in  most  cases,  to  any  foreign  material 
which  can  be  used,  such  as  Lane's  plates,  silver  wire,  nails,  ivory  pegs, 
magnesium  plates  or  tubes,  aluminum  plates,  and  even  the  hetero- 
geneous bone  plates,  screws  and  bone  chips. 

Many  discussions  and  controversies  have  arisen  during  the  last 
few  years  in  this  field  of  surgery,  a  history  of  which  would  make  an 
interesting  paper  in  itself.  Three  questions  especially  have  formed 
the  nucleus  of  this  discussion,  namely: 

1.  The  comparative  value  of  bone  grafts  and  Lane's  plates,  and 
other  foreign  materials  in  the  open  repair  of  fractures,  and  in  the  re- 
pair of  certain  bony  defects. 

2.  The  indications  for  the  open  treatment  of  fractures. 

3.  Does  the  bone  graft  have  osteogenetic  power,  and  if  so,  does 
the  periosteum  alone  possess  this  power,  or  does  the  graft  simply  form 
a  bridge  between  the  ends  of  the  bone  to  be  repaired,  over  which  re- 
generation by  conduction  occurs? 

629 


630 


INDUSTRIAL    MEDICINE    AND    SURGERY 


Lane  plates,  ox-bone  plates,  silver  wire  and  many  other  foreign 
materials  have  been  chiefly  used  in  the  past;  and  even  by  many  of  our 
best  surgeons  to-day,  for  the  open  treatment  of  fractures.  Good  re- 
sults have  obtained  in  many  cases,  but,  unfortunately,  many  others 


Fig.  165.  '  Fig.  166. 

Fig.   165. — Lane  plate  applied  to  recent  fracture. 
Fig.   166. — Three  weeks  later — plate  loosening  due  to  liquefaction. 

have  been  very  discouraging.     These  bad  results  can  be  summarized 
as  foUows: 

1.  Delayed  union:  The  presence  of  the  foreign  body  causing  a 
deficient  callous  formation  and  may  even  cause  some  liquefaction  and 
absorption  of  the  healthy  bone  to  which  the  plate  is  attached. 


fjj~^ 


J 


Fig.  167.  Fig.  168. 

Fig.   167. — Ends  of  fragments  absorbed  allowing  plate  to  become  detached  with  dis- 
placement of  lower  fragment. 

Fig.   168. — Sclerosis  of  ends  of  fragments  prevented  union. 

2.  The  wound  is  more  prone  to  infection  because  of  the  foreign 
body.  When  infection  does  occur,  the  above  mentioned  necrosis  of 
the  healthy  bone  is  the  rule. 

3.  Non-union  may  occur: 

(a)  Due  to  hquefaction,  the  plate  may  loosen  and  not  hold  the 
fragments  in  firm  apposition  (Figs.  165  and  166). 


OPEN  TREATMENT  OF  FRACTURES  631 

(6)  Due  to  infection  or  the  presence  of  foreign  body,  the  ends 
of  the  fragments  may  absorb  and  not  have  coaptation  (Fig. 
167). 
(c)  In  old  un-united  fractures,  the  ends  of  the  fragments  of 
bone  may  have  undergone  sclerosis.  It  is  the  rule  to  fresh- 
en these  ends,  but  the  sclerotic  process  may  extend  far- 
ther than  the  surgeon  expects.  Thus  a  plate  attached  to 
these  fragments  will  give  fixation,  but  no  union  occurs  (Fig: 
168). 
4,  Subsequent  operations  are  often  necessary: 

(a)  For  the  purpose  of  replacing  a  loosened  screw  or  readjust- 
ing a  plate  which  has  slipped. 
(6)  For  the  removal,  later  on,  of  the  foreign  material  because 

it  has  become  a  source  of  irritation, 
(c)  To  resort  to  some  other  plan  of  operation,  because  of  non- 
union. 
As  a  substitute  for  this  foreign  material  method,  which  has  all  of 
the  above  dire  results  to  its  credit,  we  have  the  autogenous  bone  graft, 
which,  in  the  hands  of  most  operators  accustomed  to  its  use,  has 
given  practically  100  per  cent,  good  results  in  the  repair  of  fractures 
and  other  bony  defects.     From  both  a  practical  and  a  scientific  stand- 
point, living  bone  grafts  are  more  logical,  chiefly  for  these  reasons: 

1.  There  is  no  foreign  body  present  which  later  may  have  to  be 
removed  or  may  cause  some  of  the  above  described  complications. 

2.  Infection  does  not  destroy  the  graft,  as  was  at  first  supposed; 
in  fact,  I  have  seen  the  growth  of  a  graft  apparently  stimulated  in  the 
presence  of  infection.    ■ 

3.  Union  is  more  rapid  than  where  ox-bone  plates  or  Lane  plates, 
or  other  foreign  material  has  been  used. 

4.  Non-union  in  the  old  un-united  fractures,  because  of  sclerosis 
of  the  ends  of  the  fragments,  need  never  occur,  especially  if  Albee's 
inlay  method  of  bone  grafting  is  used,  as  the  transplant  always  extends 
a  sufficient  distance  above  and  below  the  ends  of  the  fragments  to 
reach  into  healthy  bone.  For  this  reason,  the  intramedullary  graft 
is  not  always  adaptable  to  these  cases,  as  the  sclerotic  process  may 
extend  a  considerable  distance  into  the  medullary  canal. 

5.  A  Hving  bone  graft  will  conform  itself  to  the  shape  and  func- 
tion of  the  bone  into  which  it  is  grafted  (Wolff's  law). 

The  next  question,  ''The  indications  for  the  open  treatment  of 
fractures,"  likewise  forms  the  nucleus  for  a  very  lengthy  discussion. 

McAusland,  in  Surg.  Gyn.  and  Obs.,  September,  1914,  advo- 
cates the  open  method  on  most  fractures,  in  order  to  secure  perfect 
alignment  and  coaptation.  He  thinks  there  is  less  danger  to  the  soft 
parts  by  this  procedure  than  by  so  much  manipulation. 


632  INDUSTRIAL    MEDICINE    AND    SURGERY 

In  opposition  to  this  doctrine,  B.  S.  Campiche,  ^  writes  a  plea 
against  unnecessary  operations  for  fractures  which  is  very  timely. 

So  many  articles  have  appeared  in  the  last  few  years,  and  so 
many  clinical  cases  have  been  demonstrated  on  the  open  treatment 
of  fractures,  that  the  student  and  the  profession  at  large  are  almost 
led  to  believe  that  with  some  of  the  very  best  surgeons  this  is  really 
the  treatment  of  choice  for  the  majority  of  fractures.  We  know, 
however,  that  during  the  last  century  the  treatment  of  fractures  by 
the  closed  method  has  been  satisfactory  in  most  cases.  Especially 
in  the  last  decade  this  conservative  treatment  has  been  so  vastly 
improved,  due  to  the  aid  of  the  x-ray,  that  bad  results  are  compara- 
tively few. 

In  every  case  of  recent  fracture,  therefore,  conservative  non- 
operative  treatment  should  be  tried  thoroughly  and  conscientiously, 
and  the  operative  treatment  reserved  for  those  few  cases — not  over 
3  per  cent,  where  the  closed  method  has  failed. 

The  only  indications  for  open  treatment  in  recent  fractures  are: 

1.  Interposed  soft  tissues  which  prevent  coaptation  of  the 
fractured  ends. 

2.  Two  or  more  fractures  of  a  long  bone,  where  it  is  impossible  to 
secure  coaptation  and  fixation  of  each  fragment. 

3.  Certain  fractures  of  both  bones  of  forearms  or  leg,  where,  by 
every  known  manipulation,  it  is  impossible  to  secure  coaptation 
and  fixation  of  both  fractures  at  the  same  time. 

4.  Certain  fractures  into  joints,  where  loose  fragments  will  interfere 
with  the  function  of  the  joint. 

5.  A  few  atypical  fractures,  where  muscular  action  has  displaced 
'a  fragment  to  such  an  extent  that  coaptation  and  resulting  function 
can  only  be  secured  by  operation. 

In  recent  fractures,  the  appHcation  of  internal  splints  is  not  always 
necessary  as  the  ends  may  be  held  in  apposition  by  chromic  gut, 
or  kangaroo  gut,  or  even  by  external  splints  after  coaptation  has  once 
been  estabhshed.  However,  in  many  recent  fractures,  where  opera- 
tion is  necessary,  a  bone  graft  of  the  inlay  type,  made  from  the  longer 
fragment,  will  give  the  surest  fixation  and  the  quickest  results. 

In  old  fractures,  the  chief  indications  for  open  treatment  are : 

1.  Non-union. 

2.  Faulty  union  with  very  marked  deformity  or  loss  of  function. 

3.  To  restore  or  supplant  dislodged  or  destroyed  fragments. 

It  is  in  these  last  conditions  that  the  bone  graft  is  of  the  greatest 
value  and  far  superior  to  any  foreign  material. 

The  third  question  regarding  bone  grafts  concerns  the  viabihty  or 
non-viabiHty  of  the  graft.  Murphy,  Barth,  et  al.,  claim  that  the  graft 
^  Jour.  Am.  Med.  Assoc,  Vol.  Ixiv,  No.  20. 


OPEN  TREATMENT  OF  FRACTURES  633 

is  not  osteogenetic.  They  contend  that  osteoblasts  form  from  either 
end  of  the  sectioned  bone  and  circulate  through  the  Haversian  canals 
of  the  transplant,  and  that  as  they  multiply,  they  cause  absorption 
of  the  bone  cells  of  the  transplant,  the  latter  acting  only  as  a  scaffold 
or  osteoconductor — a  process  of  substitution. 

Axhausen  and  others  claim  that  the  inner  layer  of  the  periosteum 
is  the  only  portion  of  the  transplant  that  has  osteogenetic  powers, 
and  that  the  bone  in  the  graft  dies.  MacEwen,  of  Glasgow,  states 
that  the  periosteum  has  no  such  power,  but  is  simply  a  limiting  mem- 
brane for  the  osteoblasts,  regenerating  from  the  osteoblasts  of  the  graft 
itself,  and  that  this  membrane  prevents  the  spread  of  these  osteo- 
blasts into  the  surrounding  tissue. 

Many  of  our  more  recent  investigators,  Albee,  Johnson,  Phemister 
Lewis,  et  al.,  claim  that  the  graft  has  osteogenetic  powers  in  all  three  of 
its  layers — periosteum,  cortex  and  endosteum — but  more  pronounced 
in  the  periosteum  and  endosteum,  and  especially  more  marked  at 
either  end  of  the  graft,  because  here  the  new  blood  supply  to  the  graft 
is  the  richest.  In  fact,  the  osteogenetic  power  of  any  of  these  layers 
depends  absolutely  on  the  blood  supply.  A  portion  of  the  graft  near 
the  center,  and  especially  in  the  denser  cortex,  becomes  necrotic 
and  absorbs  and  is  replaced  by  the  osteoblasts  from  the  living  portion 
of  the  transplant — the  process  of  "Creeping  Substitution"  of  the  old 
bone  by  the  new. 

From  studying  the  a;-ray  findings  in  a  large  number  of  cases  I  feel 
that  we  have  conclusive  proof  of  : 

1.  The  osteogenetic  abihty  of  the  periosteum. 

2.  The  osteogenetic  powers  of  all  three  layers  of  the  graft. 

3.  The  death  of  a  certain  portion  of  the  graft  and  the  substitution 
of  osteoblasts  from  other  portions. 

4.  And  that  the  transplant  is  not  simply  a  scaffold. 
Autogenous  bone  grafts  have  become  of  paramount  value  also 

in  repairing  many  bony  defects,  such  as  those  resulting  from  complete 
loss  of  bone  due  to : 

1.  Destructive  infections,  septic,  tuberculosis,  lues,  etc. 

2.  Defects  of  development. 

3.  Benign  tumors,  as  bone  cysts,  myeloma,  etc. 

4.  Encapsulated  malignant  tumors,  as  giant-cell  sarcoma  and 
chondrosarcoma. 

These  conditions  are  extremely  important  in  industrial  surgery  as 
fractures  from  very  slight  injuries  sometimes  occur  due  to  the  presence 
of  these  pathologic  conditions.  I  have  had  two  cases  of  fracture 
and  one  case  of  alleged  injury  to  the  finger  in  which  the  accident 
was  really  coincidental,  the  real  cause  being  the  presence  of  a  bone 
cyst  in  each  case. 


634 


INDUSTRIAL   MEDICINE    AND    SURGERY 


Bone  cysts  are  the  small,  single  or  multiple  cysts  found  in  the  body 
of  the  bone  and  usually  destroy  most  of  the  cortex,  the  periosteum 
often  serving  as  the  cyst  wall.     They  are  the  end-result  of  a  low-grade 


Fig.  169. — Mviltiple  bone  cysts,  osteitis  fibrosa,  of  hands  discovered  in  an  ap- 
plicant for  work.  Under  present  compensation  laws  the  employer  could  be  held 
responsible  for  subsequent  fractures. 

inflammatory  affection  of  the  bone  and  medullary  tissues,  known  as 
osteitis  fibrosa. 


Fig.    170.  Fig.  171. 

Fig.  170. — Bone  cyst  in  little  finger.  This  girl  employee  claimed  her  work  was 
responsible  for  the  condition. 

Fig.  171. — Same  as  Fig.  170.  Three  days  after  bone  from  tibia  was  transplanted. 
Cortex  only  was  transplanted.  Fragments  of  periosteum  from  wall  of  cyst  were  left 
intact  and  growth  first  took  place  in  these  and  in  ends  of  transplant. 

Osteitis  fibrosa  causes  a  destruction  of  the  bone,  and  this  is 
gradually  replaced  by  granulation  tissue,  which,  in  time  is  converted 
into  connective  tissue,  with  or  without  the  formation  of  these  bone 


OPEN  TREATMENT  OF  FRACTURES 


635 


cysts.  Any  of  the  long  bones  may  be  affected  by  this  condition, 
especially  the  upper  end  of  the  humerus;  also,  the  small  bones  of  the 
foot  and  hand  are  often  involved.  The  bone,  if  a  cyst  is  present, 
increases  in  size  very  slowly,   as  compared  to  a  bone  affected   by 


Fig.  172.  Fig.  173. 

Fig.  172. — Same  as  Fig.  170,  eight  months  after  operation.  Note  that  transplant 
now  has  the  normal  contour  of  metacarpal  bone.      (Wolff's  Law.) 

Fig.  173. — A  bone  cyst  of  upper  end  of  humerus.  A  fracture  followed  a  slight 
collision  between  trucks. 

malignant  disease,  and  often  a  fracture  through  the  cyst  is  the  first 
evidence  of  the  disease. 

In  small  cysts,  where  the  cortex  of  the  bone  is  not  completely 
destroyed,  simply  opening  and  thoroughly  curetting  will  often  cure 


Fig.  174.  Fig.  175. 

Fig.  174. — Same  as  Fig.  173,  three  weeks  after  bone  transplant;  arm  at  right 
angles  held  by  plaster  cast.  X-ray  shows  growth  taking  place  from  periosteum,  chips 
of  bone  inserted  about  transplant  and  in  the  ends  of  the  transplant. 

Fig.  175. — Same  as  Fig.  173,  six  months  after  operation.  Note  how  transplant 
has  assumed  the  natural  contour  of  the  humerus. 


the  condition,  but  in  multiple  cysts,  where  the  shaft  of  the  bone  is 
completely  destroyed  for  a  distance,  the  periosteum  should  be  stripped 
off  and  the  entire  cyst  excised;  then  the  resulting  bony  defect  should  be 


636 


INDUSTRIAL   MEDICINE    AND    SURGERY 


repaired  by  the  insertion  of  a  bone  graft  taken,  preferably,  from  the 
patient's  own  body. 

In  repairing  fractures  or  these  bony  defects  by  the  autogenous 
graft,  the  technic  of  the  operation  is  practically  the  same.  I  will  pass 
over  the  actual  steps  of  these  operations,  but  here  are  a  few  facts 
which  should  be  emphasized : 

1.  The  bone  work  is  best  done  with  a  motor  and  the  various  shaped 
saws,  as  outhned  by  Albee,  Hogrin,  et  al.,  especially  the  twin  saws  for 
inlay  work;  a  chisel  and  mallet  may  be  used,  however. 

2.  The  greatest  asepsis  must  be  observed.  Some  advocate  the 
extreme  methods  of  never  touching  the  graft  except  with  instruments. 


1 


Fig.  176. 
Fig.  176.^ — Same  as  Fig.  173 
normal  motion  in  shoulder  joint. 

Fig.  177. — Large  bone  cyst  of  humerus 


Fig.  177. 
Eight  months  after  operation  patient  had  practically 


(Clinic  of  Dr.  A.  I.  Halstead.) 


The  graft  should  not  be  placed  in  normal  salt  solution,  as  this  washes 
away  the  blood  on  the  graft  which  nourishes  its  cells. 

3.  The  smaller  the  graft,  the  better  its  growth.  When  necessary 
to  use  a  large  graft,  save  every  small  fragment  of  bone  and  pack  about 
the  graft,  as  these  become  centers  of  osteogenesis. 

4.  Transplant  all  three  layers  and  coapt  periosteum  to  periosteum, 
cortex  to  cortex,  and  endosteum  to  endosteum.  This  is  not  essential 
for  growth  of  the  graft,  but  gives  better  blood  supply  and  quicker 
growth.     It  is  a  far  superior  method  to  the  intramedullary  grafts. 

5.  Attach  the  soft  tissues  singly  about  the  graft  and  suture  muscle 
attachments  to  the  graft  as  near  their  normal  position  as  possible. 

6.  As  early  as  possible,  allow  slight  movement  in  the  part,  so  that 


OPEN  TREATMENT  OF  FRACTURES 


637 


the  graft  will  not  only  grow,  but  will  conform  itself  to  meet  its  new 
mechanical  functions  (Wolff's  law) .     The  x-v&y  should  be  the  guide  as 


Fig.  178. — Same  as  Fig.  177,  two  weeks   after  transplant  was  made. 
Dr.  A.  I.  Halstead,  St.  Lukes  Hospital,  Chicago.) 


(Operation  by 


to  when  to  allow  this  motion,  and  it  should  not  be  done  until  the  graft 
has  become  firmly  fixed. 


Pig.  179. — Same  as  Fig.  177,    eight   months   after   operation.     Patient  is  developing 
good  function.     Illustrates  process  of  "creeping  substitution." 

7.  It  is  preferable  not  to  transplant  in  the  presence  of  infections, 
but,  contrary  to  earher  teachings,  experience  has  taught  us  that  in- 


638  INDUSTRIAL    MEDICINE    AND    SURGERY 

fection,  even  when  great  amounts  of  pus  are  present,  does  not,  as  a  rule 
destroy  the  graft.  Thus,  in  compound  fractures,  much  time  can  be 
gained,  instead  of  waiting  until  the  wound  is  perfectly  healed. 

8.  No  foreign  material,  such  as  silver  wire  or  ivory  pegs,  should  be 
used  to  hold  the  graft  in  place.  Kangaroo  gut  is  my  choice  of  material 
for  this  purpose.  • 

Figures  165  to  179  illustrate  the  various  points  brought  out 
in  this  chapter. 


CHAPTER  XXXIX 

AMPUTATIONS 

Amputations  the  result  of  injuries  occurring  in  industry  have  de- 
creased materially  during  the  last  ten  years  but  they  are  still  suffi- 
ciently prevalent  as  to  make  this  one  of  the  most  important  problems 
confronting  the  industrial  surgeon.  Their  decrease  has  been  due 
chiefly  to : 

1.  More  prompt  attention  by  the  surgeon. 

2.  Preventive  measures  reducing  the  number  of  infections. 

3.  A  more  conservative  attitude  on  the  part  of  surgeons  toward 
seriously  injured  extremities. 

4.  The  "safety  first"  movement  which  has  materially  reduced  the 
number  of  serious  accidents  in  hundreds  of  our  largest  industries. 

In  a  large  steel  mill  prior  to  the  employment  of  a  surgeon  con- 
stantly on  the  job  and  before  the  introduction  of  accident  preventive 
measures,  amputations  were  very  common.  The  commonest  cause  of 
these  amputations  was  severe  crushing  wounds  followed  by  infection. 
After  a  surgeon  was  employed,  prompt  emergency  treatment  was 
rendered  to  all  of  these  cases  with  the  result  that  the  number  of  infec- 
tions decreased  rapidly.  This  surgeon  claimed  that  the  reduction  was 
due  chiefly  to  the  use  of  tincture  of  iodin  which  was  immediately 
applied  to  wounds  no  matter  how  extensive  the  injured  area.  This 
concern  was  one  of  the  first  to  adopt  the  measures  advocated  by  the 
National  Safety  Council  and  immediately  these  serious  accidents 
became  less  frequent.  This  is  the  history  of  hundreds  of  other 
industries. 

The  cost  of  installing  these  accident  prevention  measures,  plus  the 
cost  of  employing  the  best  surgical  talent  to  render  proper  and  immedi- 
ate surgical  care  to  injured  employees  is  far  below  the  cost  of  paying 
indemnities  for  permanent  disabilities  especially  when  involving  the 
loss  of  members.  For  a  decade  this  doctrine  has  received  nation 
wide  publicity  but  still  there  are  industries  so  short-sighted  as  to  refuse 
to  adopt  such  a  straightforward  business  proposition.  Neither  the 
economic  nor  the  humanitarian  viewpoint  seems  to  appeal  to  them.  It 
is  high  time  that  both  the  States  and  Federal  governments  awake  to 
their  responsibilities  and  legislate  most  drastically  with  a  view  to 
preventing  loss  of  members  and  loss  of  life  from  industrial  accidents. 

In  civil  practice  surgeons  have  become  far  more  conservative  with 
regard  to  amputating  injured  members  than  they  were  previously. 

639 


640  INDUSTRIAL   MEDICINE    AND    SURGERY 

This  is  undoubtedly  due  to  the  fact  that  our  present  day  methods  of 
combating  infections  are  superior  to  the  old  methods;  the  transplan- 
tation of  skin,  fascia  and  bone  has  enabled  the  repair  of  wounds  which 
formerly  were  considered  hopeless;  and  there  has  been  a  growing  tend- 
ency to  delay  amputation  to  some  subsequent  date,  trying  the  re- 
parative work  first  and  later  amputating  if  this  failed.  The  severe 
infections,  especially  from  the  gas  bacillus,  following  war  injury  has 
necessitated  the  more  radical  operations  on  the  part  of  the  army 
surgeon.  Many  wounds  occurring  on  the  battlefield  have  made 
amputations  necessary  which  if  received  in  industry  would  have  yielded 
to  conservative  treatment.  The  opportunity  of  giving  more  prompt 
attention  to  the  wounds  and  the  absence  of  these  extremely  virulent 
infections  make  the  latter  course  possible.  Medical  officers  returning 
to  the  accident  surgery  of  civil  life  must  constantly  bear  these  facts  in 
mind. 

Through  the  courtesy  of  Dr.  Royal  Meeker,  Commissioner  of 
Labor  Statistics,  United  States  Department  of  Labor,  the  author  was 
able  to  obtain  the  most  recent  figures  concerning  industrial  accidents 
in  the  United  States  for  the  year  1917.  Of  the  875,000  non-fatal  in- 
dustrial accidents  causing  disability  of  over  four  weeks,  68,820  resulted 
in  amputations  of  some  member  of  the  body.  These  were  distributed 
as  follows: 

Loss  of  one  finger  or  part  of  finger 52,050 

Loss  of  two  or  more  fingers 9,100 

Loss  of  one  hand  or  arm 2,880 

Loss  of  one  foot  or  leg 1,220 

All  other  specific  losses  (including  multiple) 3,580 

Total 68,830 

When  we  consider  the  thousands  and  thousands  of  amputations 
which  result  yearly  from  accidents  received  on  the  streets,  oh  the  farms 
and  in  the  homes  which  are  not  included  in  the  above  figures,  we  obtain 
some  conception  of  the  size  of  this  problem.  The  estimated  number  of 
amputated  cases  for  all  the  nations  participating  in  the  present  war  is 
thought  to  be  between  400,000  and  500,000,  approximately  100,000  a 
year.  The  number  of  amputated  cases  from  industrial  accidents  in  the 
United  States  during  one  year  closely  approaches  the  yearly  rate  from 
this  terrible  war. 

It  is  evident,  therefore,  that  the  treatment  of  injuries  necessitating 
amputations  is  one  of  the  most  important  problems  in  industrial 
surgery.  Every  country  participating  in  the  present  war  has  made  an 
intensive  study  of  this  problem  in  all  its  aspects  with  a  view  of  obtain- 
ing the  very  best  economic  end-results  for  the  soldiers  thusly  disabled. 
As  a  result  of  these  studies,  many  valuable  principles  appUcable  to 


AMPUTATIONS  641 

industrial  surgery  have  been  conceived.  If  the  surgeon  in  civil 
practice  will  take  full  advantage  of  these  great  principles  the  unfortu- 
nate patient  in  the  future  who  loses  a  limb  should  have  many  more 
opportunities  for  a  happy  existence  than  has  been  afforded  to  these 
individuals  in  the  past. 

Finger  Amputations. — In  industry,  the  majority  of  finger  am- 
putations result  from  crushing  wounds  in  machinery;  from  saws,  heavy 
shears,  presses,  etc.,  cleanly  severing  the  finger  from  the  hand;  from 
lacerations,  nail  wounds,  splinters,  scratches  and  abrasions  which, 
through  neglect,  become  seriously  infected.  Statistics  obtained  from 
several  accident  insurance  companies  and  from  a  number  of  industrial 
surgeons  showed  a  surprisingly  high  percentage  of  amputated  fingers 
resulted  from  infections  of  minor  wounds.  In  order  to  eradicate  the 
great  loss  of  fingers  from  industrial  accidents  two  things  are  necessary : 

1.  Proper  protection  against  these  machinery  accidents; 

2.  Immediate  antisepsis  and  proper  emergency  treatment  of  all 
finger  accidents  with  a  view  of  preventing  these  infections. 

Formerly  I  followed  the  usual  procedure  in  amputating  these 
injured  fingers,  namely,  removing  a  sufficient  portion  of  the  bone  to 
enable  the  formation  of  an  anterior  and  posterior  skin  flap  which  could 
be  approximated  and  sutured.  This  practically  always  resulted  in  a 
loss  of  a  greater  portion  of  the  finger  than  actually  occurred  at  the  time 
of  the  accident.  Like  most  surgeons,  it  was  felt  that  quicker  healing 
and  a  more  sightly  result  could  be  obtained  by  such  reparative  work. 

The  great  majority  of  finger  injuries  requiring  amputation  which 
report  to  the  surgeon  are  of  the  following  types: 

1.  The  tip  of  the  finger  crushed  off  with  loss  of  only  a  slight  portion 
of  the  bone. 

2.  Most  of  the  distal  phalanx  removed  with  a  small  portion  of  the 
bone  exposed  and  the  soft  tissues  lacerated  for  a  short  distance  above 
the  point  of  severance. 

3.  The  distal  phalanx  and  the  lower  third  of  the  middle  phalanx 
crushed  off  leaving  the  bone  splintered  and  exposed  and  the  soft  tissues 
lacerated. 

4.  Complete  loss  of  the  finger  often  including  the  end  of  the 
metacarpal  bone  and  the  soft  tissues  about  the  lower  portion  of  the 
palm  lacerated. 

One  or  more  of  the  fingers  may  be  thusly  injured.  For  the  last 
five  years  I  have  treated  such  finger  injuries  as  follows: 

1.  Immediately  paint  the  wound  with  tincture  of  iodin. 

2.  With  sterile  gauze  make  gentle  but  firm  pressure  upon  the  in- 
jured part  until  the  bleeding  ceases.  When  necessary,  a  bleeding 
artery  is  grasped  with  forceps  and  ligated. 

3.  If  the  bone  is  splintered  and  protrudes  below  the  soft  tissues, 

41 


642  INDUSTRIAL    MEDICINE    AND    SURGERY 

it  is  snipped  off  even  with  the  rest  of  the  wound  by  means  of  a  bone 
forceps.     If  it  does  not  protrude  it  is  left  entirely  alone. 

4.  Loose  shreds  of  tissue  deprived  of  sufficient  circulation  are 
removed.  No  other  effort  is  made,  however,  to  trim  up  the  soft 
parts. 

5.  Narrow  strips  of  adhesive  plaster  one-eighth  to  one-fourth  of  an 
inch  in  width  are  now  apphed  over  the  wound  directly  on  the  skin. 
These  adhesive  strips  extend  up  the  finger  from  one  inch  to  two  inches 
above  the  wound.  They  are  first  apphed  on  the  flexor  surface,  pulled 
down  snugly  over  the  wound  and  then  back  over  the  extensor  surface. 
They  should  not  overlap  but  a  small  space  should  be  left  between  each 
strip  to  allow  for  oozing  and  drainage.  One  or  two  strips  should 
next  be  applied  over  the  wound  from  side  to  side.  The  portion  of  the 
adhesive  plaster  which  comes  in  contact  with  the  wound  can  be 
sterilized  by  painting  it  with  tincture  of  iodin  before  applying  it. 
After  the  strips  are  in  place,  they  should  be  lightly  painted  with  tinc- 
ture of  iodin.  Next  a  sterile  gauze  dressing  is  applied  and  the  injured 
member  bandaged. 

6.  This  dressing  should  be  changed  daily  but  the  strips  need  not 
be  removed  for  at  least  four  days  unless  infection  makes  it  necessary 
which  is  rare.  Adhesive  strips  should  be  reapplied  every  four  to 
six  days. 

By  this  method  no  more  of  the  finger  is  lost  than  actually  occurs 
at  the  time  of  the  accident.  The  adhesive  strips  prevent  retraction 
of  the  soft  tissues  from  the  bone,  pull  the  skin  edges  inward,  form  a 
bridge  for  the  new  granulations,  and  finally  cause  a  complete  approxi- 
mation of  the  soft  tissues  over  the  end  of  the  bone  with  excellent 
closure  of  the  wound.     The  advantages  of  this  fine  of  treatment  are : 

(1)  A  greater  portion  of  the  member  is  saved;  (2)  it  can  be  carried 
out  without  an  anesthetic  and  the  necessary  operative  work  required 
by  making  flaps  and  suturing;  (3)  better  drainage  is  afforded  in  case 
of  infection;  (4)  the  patient  is  more  pleased  because  at  each  subsequent 
dressing  he  can  see  that  the  maximum  saving  of  tissue  is  being  attained. 
The  only  disadvantage  is  that  in  clean  cases  the  length  of  treatment 
is  usually  prolonged  over  the  period  required  for  healing  when  the 
skin  is  immediately  approximated  by  the  flap  method. 

The  manager  of  one  of  the  departments  once  reported  to  the 
doctor's  office  complaining  of  a  slight  pain  in  his  abdomen.  One  of 
the  surgeons  placed  him  upon  a  new  operating  table  in  order  to  exam- 
ine the  abdomen.  This  table  was  a  new-fangled  contraption  which 
could  be  made  into  a  chair.  After  the  examination,  as  the  patient 
was  arising  from  the  table,  the  footpiece  fell  forward.  The  manager's 
right  index  finger  was  caught  in  the  hinge  in  some  way  and  the  tip 
completely  cut  off  at  the  middle  of  the  distal  phalanx.     Naturally 


AMPUTATIONS  643 

the  manager  was  very  outspoken  in  his  criticisms  of  such  an  office 
and  the  surgeon  was  extremely  chagrined.  I  was  immediately 
called  and  endeavored  to  explain  that  the  table  was  new  and  the  ac- 
cident was  not  the  fault  of  the  doctor  (this  case  afforded  the  example 
that  "safety  first"  methods  must  be  applied  in  the  doctor's  office 
and  in  the  hospitals).  I  explained  to  the  manager  that  we  could 
remove  the  remaining  portion  of  the  bone  back  to  the  joint,  coapt 
the  flaps  and  secure  a  good  result  with  only  the  loss  of  his  distal 
phalanx;  or  by  prolonging  the  treatment  somewhat  we  could  treat 
it  by  the  adhesive  strip  method  and  most  of  the  finger  would  grow 
back  into  place  even  including  a  portion  of  the  nail.  The  latter 
plan  was  adopted  and  in  six  weeks  the  wound  had  healed.  At  the 
time  of  the  accident  careful  measurements  of  both  index  fingers  were 
made  and  the  right  one  was  just  a  half  inch  shorter  than  the  left. 
Three  months  after  the  accident  comparison  of  the  two  fingers  showed 
only  one-fourth  of  an  inch  difference  in  length.  The  injured  finger  had 
a  natural  tapering  and  a  well-formed  nail  which  required  close  inspec- 
tion to  show  that  it  was  somewhat  shorter  than  the  other  nail.  The 
excellent  result  obtained  removed  all  criticism  concerning  the  accident. 

The  removal  of  bone  and  soft  tissue  in  order  to  attain  well-formed 
flaps  which  can  be  sutured  over  the  end  of  the  severed  finger  is  wasteful 
surgery — not  only  wasteful  to  the  employee  but  necessitating  greater 
compensation  on  the  part  of  the  employer  for  the  loss  of  the  member. 

This  adhesive  plaster  treatment  is  also  appHcable  to  many  cases 
suffering  loss  of  a  portion  of  the  palm  or  a  portion  of  the  foot.  I 
have  also  used  it  to  approximate  the  flaps  in  amputations  of  the  leg 
and  arm  where  haste  in  operating  is  indicated. 

Amputations  of  Upper  Extremity. — The  emergency  treatment 
consists  in  antisepticizing  the  wound  with  tincture  of  iodin  and  com- 
bating hemorrhage  and  shock.  The  subsequent  indications  are: 
(1)  to  secure  the  safety  of  the  patient,  and  (2)  to  secure  the  best 
functional  result.  The  best  functional  result  will  depend  upon  the 
amount  of  the  member  saved,  the  location  of  the  scar  and  especially 
the  absence  of  a  painful  scar,  and  the  adaptability  of  the  stump  to  the 
artificial  hmb  which  must  be  worn. 

When  infection  is  present  the  safety  of  the  patient  can  best  be 
conserved  by  estabHshing  good  drainage  without  endeavoring  to  form 
and  approximate  flaps.  The  InteralHed  Surgical  Congress  has  re- 
quested that  amputation  for  infection  should  be  flapless  or  with  short 
flaps  held  apart.  When  it  is  necessary  to  leave  the  incision  open 
traction  should  be  applied  to  the  skin  just  as  soon  as  possible  in  order 
to  overcome  retraction  (see  Fig.  180)  and  thus  Hmit  the  size  of  the 
resulting  scar.  After  the  infection  has  subsided  a  ream  put  ation,  in 
order  to  secure  a  proper  closure,  may  be  necessary  but  quite  frequently 


644 


INDUSTRIAL    MEDICINE    AND    SURGERY 


approximation  can  be  secured  by  the  adhesive  piaster  method  out- 
lined above  especially  in  the  smaller  extremities. 

The  location  of  the  scar  in  arm  amputations  should  either  be 
posterior  or  preferably  across  the  end  of  the  stump  as  in  using  the 
stump  pressure  is  usually  exerted  laterally  and  not  on  the  end. 
A  wrist  stump,  however,  requires  frequent  end  pressure  and  for  this 
reason  a  long  palmar  flap  with  the  scar  at  the  back  of  the  wrist 
is  preferable.  In  all  other  locations  the  short  anteroposterior  flaps 
will  be  found  the  most  useful.  Whenever  possible  the  muscles  and 
deep  fascia  should  be  sutured  over  the  end  of  the  bones  in  order  to 
prevent  an  adherent  scar  and  to  give  sufficient  bulk  to  form  a  cushion. 


Fig.  180. — Traction  applied  to  skin  to  prevent  retraction.  Stump  extension  with  a 
modified  Thomas  splint.  (Adapted  from  Sinclair.)  "A  Thomas  knee  splint  is  cut 
down  and  a  9-inch  square  riveted  on  to  the  side  bars  12  inches  beyond  the  end  of  stump. 
An  8-inch  circle  of  aluminum  is  attached  by  gauze  and  glue  to  the  skin  of  the  stump  so 
as  to  be  6  inches  distal  to  the  cut  surface.  Extension  is  made  from  the  ring  to  the 
square  either  by  tapes  or  rubber  bands.  The  square  acts  as  a  pedestal  and  also  for  the 
attachment  of  the  extensions."     (Courtesy,  "  The  Military  Surgeon.") 

Redundancy  of  tissue  affording  excessive  motion  is  to  be  avoided 
as  in  this  case  the  skin  may  become  irritated  from  rubbing  against  the 
socket  of  the  artificial  appliance.  In  amputations  of  the  forearm  ^oft 
tissues  must  be  carefully  sutured  between  the  ends  of  the  ulna  and 
radius  to  prevent  union  between  these  bones  as  such  union  interferes 
with  pronation  and  supination. 

The  Division  of  Military  Orthopedic  Surgery  of  the  Office  of  the 
Surgeon  General  of  the  United  States  Army  has  made  an  extensive 
study  of  the  preferable  sites  of  amputation  as  related  to  the  future 
requirements  of  the  artificial  appliance.  These  favorable  sites  are 
graphically  shown  in  Fig.  181. 


AMPUTATIONS 


645 


I. 

PREFERABLE  SITES  of  AMPUTATION  from 
ARTIFICIAL  LIMB    STANDPOINT 

(UPPER  EXTREMITY) 


>t 


:>' 


,  Leave  Humeral  Head.if  possible  as  it  la of 

advantage  in  filling  Glenoid  Cavity 

Lfpp<?r  Bonp  Limit  of  funcHonal 
Valu$  in  Arm  Amputation. 

'inches  of  bone  shortest  stump  oF  valu^ 
in  activating  appliance 


Bone  Uvel  of  Greatest  Funcfiona!  Value 
in  Arm  Amputation 


i 


Upper  Bone  Limit  of  Functional  Value 
—         m  Forearm  Amputation 

3  inches  of  bon(?  shortest  of  value 


-Bone  Level  of  Greatest  Functional  Value 
in  Forearm  Amputation  Because  of 
Preservation  of  Power  of  Pronation 
and  Supination. 

Save  Every  Portion  oF  Hand  Possible 

Short  anterior  and  posterior  flaps  the  rule 
except  at  wrist  where  long  palmar  flap  is  used. 


AMPUr/JT/ONfSoneDii^/s/dnJ  /A/  5H/ID£D  /i/?5/}  C/ZV" 
SAHSfACrORy  fROMART/f/C/AL  l/MS  SrA^DPO/NZ 


Fig.   181. — Courtesy,  "  The  Military  Surgeon. 


646  INDUSTRIAL   MEDICINE    AND    SURGERY 

In  a  report  from  the  Orthopedic  Division  pubhshed  in  the  Military 
Surgeon  for  February,  1918,  the  following  statements  regarding  the 
site  for  amputations  in  the  upper  extremity  are  made: 

"'In  the  hand  it  is  generally  recognized  that  the  importance  of 
preserving  as  much  as  possible  of  the  thumb  and  fingers  need  hardly 
be  emphasized.  A  thumb,  or  part  of  a  thumb,  together  with  some 
portion  of  fingers  or  hand  to  which  it  can  be  opposed,  is  more  useful 
than  any  artificial  contrivance  which  can  be  fitted.  In  this  region 
irregular  operations — trimming,  removal  of  splinters  of  bone  or 
sequestra,  etc.,  are  likely  to  give  better  functiomal  results  than  any  set 
amputation.' 

"At  the  wrist  there  is  a  decided  advantage  in  disarticulation  on 
account  of  the  better  preservation  of  the  forces  of  pronation  and 
supination,  which  are  now  being  used  to  activate  the  artificial  hand. 
Moreover,  in  this  case  it  is  easy  to  put  the  necessary  mechanism  below 
the  wrist.  A  further  advantage  in  amputation  at  this  point  is  that  the 
enlargement  of  the  wrist  is  a  decided  aid  in  holding  the  artificial  arm 
in  position. 

"In  the  forearm,  amputation  in  the  lower  part  of  the  middle  third 
gives  a  good  and  useful  stump.  While  the  circulation  of  stumps 
in  the  lower  third  is  often  poor,  yet  the  better  preservation  of  the  power 
of  pronation  and  supination  that  is  secured  by  amputating  as  near  the 
wrist  as  possible  makes  this  site  desirable;  to  ensure  freedom  of  these 
movements  every  precaution  should  be  taken  at  the  time  of  operation 
to  guard  against  union  of  the  ends  of  the  bones  by  osseous  or  fibrous 
adhesions.  Above  the  middle  of  the  forearm  it  becomes  of  increasing 
importance,  the  nearer  the  elbow  is  approached,  to  save  every  fraction 
of  an  inch  possible.  When  the  stump  is  less  than  three  inches,  great 
difficulty  is  experienced  in  preventing  it  from  shpping  out  of  the  socket, 
owing  particularly  to  the  action  of  the  biceps  tendon  during  flexion  of 
the  elbow,  and  with  the  short  stump  there  is  also  naturally  a  decided 
loss  in  leverage.  'If  it  is  impossible  to  get  a  forearm  stump  extending 
at  least  an  inch  and  a  half  below  the  insertion  of  the  tendon  of  the 
biceps,  amputation  above  the  condyles  of  the  humerus  is  to  be 
preferred.' 

"In  the  upper  arm  the  lowest  point  at  which  amputation  is  desirable 
is  just  above  the  condyles  (about  two  inches  above  the  center  of  the 
joint);  the  reasons  for  this  are  similar  to  those  already  discussed. 
From  this  point  the  longer  the  stump  the  better.  Above  the  middle  of 
the  upper  arm  the  surgeon  must  utilize  every  surgical  expedient  to  save 
all  the  length  possible ;  the  power  to  control  an  artificial  arm  diminishes 
to  an  alarming  degree  with  each  loss  of  even  a  shght  portion  of  bone. 
But  httle  can  be  expected  from  a  stump  in  which  the  bone  extends  less 
than  two  inches  below  the  axillary  fold.     Since  a  terminal  and  even  an 


AMPUTATIONS  647 

adherent  scar  is  not  particularly  objectionable  in  the  upper  extremity, 
owing  to  the  pressure  being  exerted  laterally,  skin-grafting  (usually 
inadvisable  in  a  leg  stump)  may  be  employed  to  cover  defects  rather 
than  a  reamputation  performed.  Moreover,  in  some  cases,  'a 
good  deal  can  be  gained  by  removing  wholly  or  in  part  the  folds  of  the 
axilla,  that  is,  the  pectoralis  major  and  the  teres  minor.  This  has 
been  done  with  good  results  and  seems  to  be  an  operation  worth 
doing  in  suitable  cases.'  It  is  always  advisable  to  retain  any  portion 
of  the  upper  end  of  the  humerus,  even  if  only  the  head,  rather  than 
to  remove  it  (as  is  necessary  under  similar  conditions  in  the  thigh), 
since  the  appliance  is  fitted  much  more  easily  when  the  glenoid 
cavity  is  filled." 

Amputations  of  the  Lower  Extremity. — The  emergency  treatment 
and  the  same  general  indications  described  for  the  upper  extremity 
are  also  applicable  to  amputations  performed  on  the  lower  extremity. 
Fig.  180  shows  the  method  of  extension  which  can  be  appHed  to  the 
lower  limb  when  infection  necessitates  the  '^ guillotine"  or  Sapless 
amputation. 

The  location  of  the  scar  and  the  condition  of  the  tissue  at  the  end 
of  the  stump  are  of  prime  importance  as  end-bearing  stumps  are  be- 
coming more  and  more  popular.  Practically  all  artificial  legs  are  de- 
signed by  the  makers  with  a  view  of  carrying  the  weight  either  on  the 
ischial  tuberosity  or  on  the  tuberosities  of  the  tibia.  H.  H.  M.  Llyle,^ 
has  pointed  out  the  importance  of  end-bearing  stumps  in  a  large  pro- 
portion of  cases.  The  importance  of  such  stumps  has  been  further 
demonstrated  by  E.  M.  Little^  reporting  on  the  amputated  cases  at 
Roehampton. 

Dr.  David  Silver  advocates  the  closest  co-operation  between  the 
surgeon  and  the  artificial  limb  maker  in  order  to  increase  the  number 
of  end-bearing  stumps;  ''for  it  is  obvious  that  the  transference  of  even 
a  part  of  the  weight  to  the  end  of  the  stump  will  conduce  to  greater 
comfort  and  improve  function." 

With  this  in  mind  the  placement  of  the  scar  is  exceedingly  impor- 
tant. Tuffier  says:  "In  the  leg,  amputation  by  circular  incision  re- 
sults in  terminal  cicatrices  which  have  every  defect  of  situation,  shape 
and  adherence;  on  this  point  all  surgeons  are  agreed."  Therefore, 
leg  fl^ps  should  be  made  of  unequal  length  thus  forming  the  scar  along 
the  lateral  and  preferably  the  posterior  surfaces.  Here  again  the  mus- 
cles and  fascia  should  be  carefully  sutured  over  the  end  of  the  bone  in 
order  to  secure  a  sufficient  pad  of  soft  tissue.  Llyle  very  aptly  states 
that  "the  best  formed  stump,  if  not  quickly  put  to  use  as  a  real  sup- 
port, may  become  atrophied  and  useless." 

'Jour.  Am.  Med.  Assoc,  Vol.  xviii,1914. 
2  Brit.  Med.  Jour.,  Oct.  27,  1917. 


648  INDUSTRIAL   MEDICINE    AND    SURGERY 

The  preferable  sites  of  amputation  in  the  lower  extremity  are  shown 
in  Fig.  182.  This  chart  was  also  prepared  by  the  Division  of  Ortho- 
pedic Surgery  of  the  Surgeon  General's  Office  and  is  explained  by  them 
as  follows: 

"  In  the  foot  it  is  undesirable  to  save  a  soHtary  toe,  even  the  great- 
est toe.  Amputation  just  back  of  the  heads  of  the  metatarsal  bones, 
in  front  of  the  attachment  of  the  tibiales  and  peronei,  may  be  fitted  so 
as  to  give  a  useful  foot;  but  amputation  through  the  tarsus,  back  of 
the  muscular  attachment  just  mentioned,  is  usually  unsatisfactory, 
as  sooner  or  later  a  condition  of  equinus  is  likely  to  result  due  to  con- 
traction of  the  unopposed  calf  muscles  and  walking  becomes  difficult 
or  impossible. 

"  At  the  ankle  a  satisfactory  end-bearing  stump  is  usually  secured 
by  Syme's  amputation,  in  which  the  bones  are  divided  just  above  the 
joint  line  and  at  right  angles  to  the  long  axis  of  the  tibia.  The  Syme  is 
preferable  to  the  Pirogoff,  as  it  gives  more  room  for  an  ankle  joint 
mechanism  and  avoids  the  difficulty  frequently  encountered  in  keeping 
the  end  of  the  os  calcis  in  position. 

"In  the  lower  leg  the  middle  third  is  generally  considered  the  most 
favorable  site;  many  artificial  Hmb  makers  prefer  amputation  at  the 
middle  of  the  leg  to  any  amputation  back  of  the  toes.  With  proper 
surgical  precaution  and  a  good  modern  artificial  limb,  end-bearing 
usually  should  always  be  secured  and  the  gait  be  practically  normal. 
The  fibula  should  always  be  cut  an  inch  shorter  than  the  tibia  and  the 
sharp  point  of  the  tibial  crest  removed  in  the  usual  manner.  The  lower 
third  is  not  so  favorable;  the  tibia  is  smaller  at  this  point  and  not  so 
satisfactory  for  end-bearing,  and  circulatory  disturbances  are  not 
infrequent.  In  the  upper  third  a  very  short  stump  of  course  gives 
poor  leverage  but  fair  results  are  sometimes  obtained  with  as  Httle  as 
two  inches  of  bone.  However,  a  stump  as  short  as  this  is  usually  in- 
advisable, as  it  will  ordinarily  have  to  be  fitted  with  the  older  type  of 
knee-bearing  leg — with  the  tibial  stump  bent  to  a  right  angle;  this  has 
only  the  advantage  of  direct  knee-bearing,  which  can  usually  be  se- 
cured by  amputation  at  the  lower  end  of  the  femur,  and  possesses  all 
the  disadvantages  incident  to  artificial  knee-joint  construction. 

"Emphasis  needs  to  be  laid  on  the  fact  that  the  old  'site  of  election' 
(four  inches  below  the  knee)  was  intended  to  produce  this  direct 
knee-bearing  stump  and  must  now,  therefore,  be  entirely  disregarded. 

"In  the  thigh  the  best  amputation  is,  of  course,  one  just  above  the 
condyles;  when  conditions  permit,  the  patella  may  with  advantage 
be  utilized  to  cover  the  end  of  the  femur.  (The  preservation  of  a  part 
of  the  condyles,  with  the  patella  imbedded  in  them,  is  favored  by  some 
limb  makers,  as  it  enables  the  weight  of  the  apparatus  to  be  borne  by 
,  the  leg  itself.)     Above  this  point  all  the  length  possible  should  be 


AMPUTATIONS 


649 


II 

PREFERABLE  SITES  0/ AMPUTATION  f^o"' 
ARTIFICIAL  LIMB  STANDPOINT. 

(LOWER  EXTREMITY] 


Abovp  this  upper  fimit  disarticulatc- 
Two-  step  operdtion  usually  preferable 

^Upper  Bon(?  Limit  of  FuncHonal 
^  Value  in  Thigh  Amputation 

Two  mcti  stump  measured  from 
pubes  shortest  ever  of  value. 


Bon<?  Level  of  Greatest  Functional 
Value  in  Ttii^h  Amputation. 


Upper  Bone  Limit  of  Functional 
Value  in  Le^  Amputation. 

inches  of  Tibia  shorfest  ever  of  value. 


►Bone  Level  of  Greatest  Functional  Value 
iLe^Amputation.Alor  Just  Below  the  Middle. 

^8  inches  of  bone  best  from  artificial  limb  standpoinf. 

Bone  Level  of  Good  Functional  Value  But 
Unsatisfactory  for  Fitting. 

r  Bono  Limit  of  functional  Value 
in  Foot  Amputation. 

'S/ir/5f/lCT0R/  fROM/i/^r/r/CML  UMB  STANDPO/NT. 


Fig.   182. — Courtesy,  ''The  Military  Surgeon." 


650  INDUSTRIAL    MEDICINE    AND    SURGERY 

saved,  as  the  possibiKty  of  end-bearing  decreases  rapidly  as  the  upper 
limit  of  usefulness  as  regards  leverage  is  approached.  A  stump  in 
which  the  bone  is  less  than  three  inches,  measured  from  the  pubis,  is  of 
little  value,  and  exarticulation  is  preferable.  ^  The  linea  aspera  requires 
attention  in  the  same  manner  as  the  crest  of  the  tibia. 

"To  avoid  shock  a  subtrochanteric  or  intratrochanteric  amputa- 
tion may  be  first  performed  by  the  flapless  or  short  flap  method,  and 
the  removal  of  the  end  of  the  bone  left  for  a  later  period. 

"It  is  now  possible  to  fit  an  exarticulation  of  the  hip  with  a  very 
satisfactory  appliance;  in  some  cases  the  gait  is  even  better  than  with 
the  shorter  stumps." 

The  best  functional  result  in  all  amputations  depends  upon  proper 
surgical  procedures  at  the  time  of  operating  and  upon  the  subsequent 
care  of  the  stump.  During  the  operation  the  following  points  must 
particularly  be  borne  in  mind:  (1)  The  periosteum  should  be  carefully 
severed  with  a  knife  just  above  the  level  at  which  the  bone  is  to  be 
divided,  as  shredded  periosteum  frequently  causes  exostosis  and  spur 
formation;  (2)  at  least  one  inch  of  the  nerve  should  be  removed  by 
drawing  it  down  from  its  sheath  and  severing  with  scissors  or  a  knife, 
and  then  suturing  the  sheath  over  the  retracted  end;  (3)  all  blood- 
vessels should  be  carefully  ligated  instead  of  trusting  to  crushing  with 
artery  forceps;  (4)  a  sufficient  amount  of  muscle  and  fascia  should 
be  drawn  over  the  end  of  the  bone  and  sutured  with  catgut;  (5)  the 
viability  of  the  skin  flaps  should  be  assured;  it  is  better  to  only  partially 
approximate  these  flaps  rather  than  submit  them  to  undue  tension. 

The  subsequent  treatment  of  the  stump  is  constantly  directed 
toward  overcoming  muscular  weakness  and  limitation  of  motion. 
Lack  of  sufficient  strength  to  successfully  use  an  artificial  limb  is  one 
of  the  chief  causes  of  discouragement  in  the  patient.  Pain  and  tender- 
ness in  the  stump  will  cause  the  patient  to  postpone  all  efforts  to  use 
the  member  thus  causing  more  or  less  atrophy  from  disuse.  Limi- 
tation of  motion  will  often  prevent  the  application  of  an  artificial 
appliance  and  will  further  rob  the  patient  of  the  incentive  to  use  the 
part.  All  of  these  conditions  tend  to  destroy  the  best  functional 
result.  To  overcome  these  conditions,  certain  routine  measures  must 
be  applied  to  the  stump  combined  with  functional  re-education  of  the 
member. 

A  systematic  plan  of  treatment  destined  to  meet  all  indications 
is  set  forth  in  instructions  issued  by  the  Surgeon  General's  Office  of 
the  United  States  Army. 

"  While  the  incision  is  healing,  at  each  dressing  the  stump  should  be 

^  This  statement  has  recently  been  contested  by  some  excellent  surgeons  who 
claim  that  the  head  of  the  femur  left  intact  facilitates  application  and  function 
of  artificial  appliance. 


AMPUTATIONS  651 

moved  to  the  full  limit  in  the  opposite  direction  to  that  in  which  a 
contracture  is  likely  to  develop.  In  forearm  stumps,  movement  should 
be  carried  out  in  supination  and  extension;  in  upper  arm  amputations,  in 
an  upward  and  backward  motion;  in  the  lower  leg,  in  extension  and  in 
thigh  amputations,  in  extension  (securing  hyperextension)  and  adduc- 
tion. It  is  usually  advisable  to  keep  all  stumps  elevated  while  the  patient 
is  recumbent  and,  therefore,  particular  attention  should  be  directed 
to  thigh  amputations  because  this  position  favors  a  flexion  contracture; 
to  counteract  this  tendency  it  is  recommended  that  once  or  twice 
each  day  the  pillow  be  removed  from  under  the  stump  and  placed 
under  the  buttock,  thus  allowing  the  stump  to  drop  into  hyperexten- 
sion. Further,  advantage  should  be  taken  of  the  position  in  which  the 
stump  is  dressed  in  order  to  guard  against  the  tendency  to  contracture; 
thus  in  forearm  stumps,  where  supination  is  hardest  to  control, 
the  dressing  should  be  applied  so  as  to  maintain  the  bones  in  this 
position.  When  the  incision  has  had  to  be  left  open,  movement 
of  the  joint  in  the  other  directions,  also,  should  be  added  as  soon  as 
conditions  permit. 

"As  soon  as  the  wound  is  healed,  or  practically  so,  and  while  the 
patient  is  still  confined  to  bed,  the  following  routine  (modified  from 
Hirsch)  is  begun: 

"1.  Massage. — The  stump  should  be  massaged  for  a  period  varying 
from  ten  to  thirty  minutes,  once  or  twice  a  day,  according  to  its 
size  and  position.  The  region  of  the  incision  should  naturally  be 
avoided  for  the  first  few  times  and  care  taken  not  to  make  undue 
tension  on  the  fresh  scar.  As  rapidly  as  the  tolerance  of  the  stump 
will  permit,  the  depth  and  the  force  of  the  massage  should  be  increased 
up  to  the  full  normal  limits. 

"2.  Bandaging. — After  the  massage,  the  stump  should  be  redressed 
with  a  cotton  dressing,  bandaged  snugly  in  place,  or  if  it  is  well  healed, 
a  bias  flannel  bandage  alone  may  be  used.  The  latter,  when  properly 
applied  in  several  layers,  gives  a  firm,  even  pressure. 

"3.  Pressure  Exercise. — The  patient  is  directed  to  press  the  end  of 
the  bandaged  stump  against  a  cushion,  placed  in  the  bed  or  against  a 
frame.  This  must  be  begun  with  care,  pressure  being  made  at  first 
for  only  several  minutes  at  four  or  five  hour  intervals;  if  there  is  no  un- 
favorable reaction,  it  should  be  increased  gradually  up  to  five  or  ten 
minutes  every  two  hours  and  then  every  hour. 

"4t.  Movements. — After  each  pressure  exercise,  active  movements 
of  the  stump  are  to  be  made  in  all  directions,  to  the  full  limits  of  the 
joint  motion,  for  three  to  five  minutes.  Later,  some  form  of  resistance 
movements  may  be  added  to  advantage,  in  order  to  still  further  build 
up  the  strength  of  the  muscles  controlling  the  stump  and  so  make 
the  early  use  of  the  artificial  limb  more  easy. 


652  INDUSTRIAL    MEDICINE    AND    SURGERY 

"5.  Baths,  etc. — Hydrotherapy  in  the  form  of  hot  packs  or  warm 
baths,  or  electric  hght  baths  are  to  be  used  as  indicated  to  improve 
the  circulation  and  hasten  absorption.  The  contrast  bath  is  par- 
ticularly valuable,  the  rapid  dilatation  and  contraction  of  the  blood- 
vessels which  it  produces  causing  a  marked  improvement  in  the  local 
vascular  and  nervous  tone;  the  simplest  method  of  apphcation  consists 
in  the  use  of  two  buckets,  the  stump  being  plunged  first  into  the  hot 
water  and  then  into  cold,  as  rapidly  as  the  patient  can  change  it,  for 
five  or  ten  minutes. 

"  When  the  patient  is  able  to  leave  the  bed,  the  measures  just  out- 
lined are  to  be  continued,  but  in  the  case  of  leg  amputations  the  pres- 
sure exercise  is  to  be  discontinued  as  described  and  direct  weight- 
bearing  on  the  stump  begun.  A  stool  of  the  proper  height  and 
a  cushion  are  provided  and  the  patient,  supporting  himself  with  his 
hands,  allows  at  first  only  a  little  weight  to  rest  upon  the  bandaged 
stump;  the  amount  of  weight  borne  and  the  time  are  then  gradually 
increased,  in  a  manner  similar  to  that  used  in  the  pressure  exercise 
in  bed,  until  the  entire  weight  can  be  taken  on  the  stump.  The 
patient  may  then  carefully  begin  to  hammer  on  the  stool  with  the  end 
of  the  stump,  in  imitation  of  the  pounding  which  takes  place  in 
walking  with  an  artificial  limb  provided  for  end-bearing.  As  soon 
as  the  patient  can  stand  alone  for  a  long  time  without  getting  tired, 
and  with  no  other  support  than  that  needed  to  balance  himself,  a 
temporary  leg,  properly  provided  for  end-bearing,  may  be  fitted  and 
walking  begun,  crutches  being  used  guardedly  and  dispensed  with  as 
soon  as  possible.  For  a  long  time,  however,  the  patient  should  con- 
tinue to  practise  standing  on  the  bare  stump  on  a  hard  surface  three 
times  a  day. 

"The  value  of  end-bearing  is  generally  admitted.  The  measures 
suggested,  both  with  respect  to  the  amputation  and  the  care  of  the 
stump,  are  simple  and  have  borne  the  test  of  cHnical  experience.  Their 
persistent  use  is  urged  upon  all.  While  it  is  recognized  that  in  very 
many  cases  the  presence  of  long-continued  infection  will  seriously  delay 
the  institution  of  proper  after-treatment,  yet  much  good  may  still  be 
expected  even  when  begun  late,  and  there  will  be  a  large  number  in 
which  the  routine  may  be  followed  from  the  first.  The  ideal  cases 
will  obviously  be  those  requiring  reamputation,  which  will  naturally 
be  deferred  until  entirely  favorable  conditions  can  be  secured  and 
which  can,  therefore,  be  performed  solely  with  regard  to  the  require- 
ments of  the  artificial  limb.  Even  when  the  attempt  to  secure  end- 
bearing  is  unsuccessful  rigid  adherence  to  the  routine  just  described 
is  still  to  be  insisted  on;  the  improved  conditions  of  the  stump,  the 
greater  freedom  from  pain  and  the  avoidance  of  much  of  the  discom- 
fort usually  associated  with  the  early  use  of  an  artificial  hmb  are  more 
than  sufficient  to  repay  one  for  the  additional  trouble. 


AMPUTATIONS 


653 


"The  joint  motion  should  be  tested  by  the  surgeon  at  regular  in- 
tervals, particularly  in  bed-ridden  infected  cases,  in  order  to  be  cer- 
tain that  the  full  range  is  retained.  At  the  elbow,  in  addition  to  veri- 
fying the  presence  of  complete  flexion  and  extension,  the  freedom  of 
rotation  of  the  radial  head  must  be  determined  and  particularly  with 
reference  to  outward  rotation  (supination) ;  the  value  of  the  movements 
of  pronation  and  supination  in  activating  the  artificial  hand  will  de- 


FiG.   183. — -Temporary  artificial  legs.      (Courtesy,  "The  Military  Surgeon.") 


pend  upon  the  degree  possible,  the  loss  of  even  a  few  degrees  making 
a  great  difference.  Of  the  movements  of  the  shoulder  girdle  (upward, 
downward,  forward,  backward,  and  circumduction),  the  upward  and 
backward  ones  are  the  most  important ;  these  may  be  easily  tested  with 
the  patient  lying  at  the  edge  of  the  bed  or  turned  on  the  opposite  side. 
At  the  knee  it  is  well  to  remember  that  there  are  normally  a  few  de- 
grees of  recurvation.  In  testing  the  hip,  the  presence  or  absence  of 
flexion  deformity  may  be  determined  (following  the  method  used  in 
hip  disease)  by  flexing  the  opposite  thigh  fully  on  the  trunk,  the  stump 
rising  from  the  bed  when  a  contracture  exists,  or  with"  the  patient 


654 


INDUSTRIAL    MEDICINE    AND    SURGERY 


lying  on  the  face,  the  degree  of  hyperextension  may  be  determined 
(again  as  in  the  similar  test  used  in  hip  disease)  by  lifting  the  stump 
with  one  hand  while  holding  down  the  buttock  with  the  other;  in  test- 
ing the  amount  of  adduction,  movement  of  the  pelvis  should  be  con- 
trolled with  one  hand  while  the  other  manipulates  the  stump." 

In  order  to  accustom  patients  to  the  early  use  of  the  stump  and 
limb,  and  to  prevent  undue  atrophy  and  shrinkage  of  the  member, 
temporary  artificial  limbs  have  been  devised  for  the  use  of  amputated 
cases  among  the  soldiers  in  the  United  States  Army.  These  tempo- 
rary appUances  also  enable  early  introduction  of  functional  re-educa- 
tion as  a  definite  part  of  the  therapeutic  treatment  of  these  cases. 


Fig.  184. — Temporary  artificial  arm,  plaster  paris  socket,  with  various  appliances 
which  help  to  stimulate  the  early  use  of  the  remaining  portion  of  the  member.  {From 
"The  Military  Surgeon") 

These  temporary  limbs  are  made  by  covering  the  stump  and  limb 
with  felt,  then  moulding  a  plaster-of-Paris  socket  carefully  over  the 
part  and  fitting  it  snugly  against  the  end  of  the  stump  and  the  tuber- 
osities which  must  help  support  the  weight.  Into  this  plaster-of-Paris 
socket  are  incorporated  a  stock  frame,  similar  to  the  lower  portion  of 
a  crutch,  when  an  artificial  leg  is  desired;  or  a  stock  clamp  made  of  a 
piece  of  flat  iron  with  wing  end  and  rivet,  when  an  artificial  arm  is 
desired.  Rings  are  securely  embodied  in  the  upper  end  of  the  plaster 
socket  into  which  web  straps  can  be  inserted  in  order  to  fasten  the 
socket  to  the  body.     Fig.  183  illustrates  these  temporary  artificial  legs 


AMPUTATIONS 


655 


while  Fig.  184  shows  an  artificial  arm  with  the  various  utensils  which 
can  be  attached  to  the  clamp. 

Many  other  appliances  can  be  incorporated  in  these  artificial 
arms.  For  instance,  one  arm  socket  has  attached  to  it  a  tennis  racket 
and  this  patient  has  become  an  expert  tennis  player  although  he  has 
lost  his  forearm  at  the  middle  third.  Another  patient  has  an  attach- 
ment on  his  plaster  socket  which  enables  him  to  play  golf  while  still 
another  enjoys  a  game  of  billiards  by  means  of  a  special  ball  and  socket 
joint  attached  to  his  artificial  appliance.  Special  hooks  and  clamps 
have  been  invented  which  enable  the  grasping  of  saws,  chisels,  ham- 
mers and  other  tools  thus  enabling  these  patients  to  work,  thereby 


Fig.  185. 


-Tennis  rackets,  billiard  cues,  golf  clubs  and  other  appliances  can  be 
fastened  to  these  sockets. 


gaining  more  and  more  strength  in  the  member  plus  the  psychothera- 
peutic benefits  of  both  work  and  play  (Fig.  185). 

A  fuU  description  of  these  temporary  appliances  can  be  found  in 
the  Military  Surgeon  for  April,  1918.  Every  surgeon  caring  for  the 
accident  cases  in  industry  should  famiharize  himself  with  these  ad- 
vanced methods  of  handhng  amputated  cases.  No  longer  should 
we  be  contented  with  merely  operating  on  these  patients  securing 
good  surgical  results  and  then  allowing  the  patients  to  wait  several 
months  before  securing  the  artificial  limb,  finally  leaving  the  appHca- 
tion  of  this  limb  purely  to  the  judgment  and  commercial  instincts 
of  the  artificial  Hmb  manufacturer.     The  fitting  of  the  permanent  ar- 


656 


INDUSTRIAL   MEDICINE    AND    SURGERY 


tificial  appliance  is  just  as  definitely  a  part  of  the  surgeon's  work  as  is 
the  performing  of  the  operation. 

Lt.  Col.  David  Silver  says: 

"  In  studying  the  problem  of  the  artificial  arm,  one  is  struck  again 
and  again  by  the  value  of  relatively  simple  appliances  and  the  impor- 
tance of  thorough  training  in  their  use.  With  a  simple  wrist  strap,  an 
armless  man  is  able  to  dress  and  feed  himself  and  do  most  of  his 
ordinary  daily  acts.     A  strap  over  the  shoulder,  properly  provided 


INSTRUCTION 

LA6RATORY 

AKK\V   MEDKiAL. 

tA  USEUM  - 


Fig.  186. — -Teaching  amputation  cases  to  use  artificial  legs  at  Walter  Reed  Hospital. 

with  a  ring,  is  sufficient  to  enable  the  one-armed  man  to  plow,  use  a 
wheelbarrow,  spade  and  pitch  hay.  A  single  working  appliance  has 
enabled  a  man  who  suffered  a  disarticulation  of  the  right  shoulder 
and  an  amputation  of  the  left  forearm  to  be  entirely  independent. 
After  all  it  is  a  matter  of  a  little  brains  and  much  perseverance." 

During  the  long  weeks  of  convalescence  following  amputations, 
the  surgeon  has  it  within  his  power  to  imbue  these  patients  with  the 
sentiments  expressed  by  Michael  Dowling  who  philosophically  says, 
"A  man  may  be  worth  $100,000  a  year  from  his  neck  up  and  worth 
only  $1.50  a  day  from  his  neck  down." 


CHAPTER  XL 
THE  EMPLOYEE'S  FOOT 

After  the  present  war  millions  of  young  men  will  be  returned  to 
civil  life  who  have  learned  the  lesson  of  the  proper  care  of  the  feet. 
Every  soldier  in  the  army,  including  medical  officers,  realizes  that  as 
a  nation  we  have  displayed  extreme  ignorance  in  the  past  regarding  the 
type  of  shoe  worn,  the  health  of  the  foot  and  the  resulting  lowered 
efficiency. 

Industrial  surgeons  can  increase  the  competency  of  the  working 
forces  and  can  reduce  the  time  lost  from  work  by  giving  more  scientific, 
as  well  as  common  sense  attention  to  the  employee's  foot.  Not  only 
will  the  comfort  and  happiness  of  the  employees  be  increased,  but 
the  financial  returns  from  this  service  alone  will  almost  pay  the 
expenses  of  the  doctor's  office. 

The  shoes  of  the  working  man  and  woman  should  receive  our  first 
consideration.  Very  few  people  wear  proper  shoes.  As  a  rule  they 
are  either  too  narrow  or  too  short.  Often  the  narrow  shoes  with  pointed 
toes  are  bought  for  dress-up  purposes  and  when  they  become  a  httle 
worn  out  are  used  for  work.  Heels  are  usually  too  high,  especially 
among  the  women  employees,  many  of  whom  insist  upon  wear- 
ing the  high  French  heels  while  at  work.  Oversized  shoes  are. worn 
by  some  employees  and  are  equally  bad  as  their  feet  are  thus  subject 
to  trauma  from  the  shoe  rubbing  up  and  down. 

Accidents,  especially  from  falls,  frequently  result  from  faulty 
shoes.  A  sole  which  is  worn  nearly  through  permits  a  nail  or  spHnter 
to  puncture  the  foot.  A  loose,  flapping  sole  will  often  cause  a  fall 
which  results  in  a  few  days  time  lost  from  work  or  even  perma- 
nent disabihty.  High  heels  worn  by  women  are  a  common  cause  of 
falls  while  descending  a  flight  of  stairs.  During  one  year  I  treated 
fourteen  fracture  cases  among  girls  and  all  but  four  of  these  resulted 
from  falls  which  could  be  traced  to  their  high  heels.  The  factory 
inspector  of  one  of  our  largest  industrial  states  recently  told  the  author 
the  fracture  rate  from  accidents  had  increased  almost  50  per  cent, 
during  the  last,  year  (1918);  he  stated  that  this  was  due  to  the  greater 
number  of  women  employed  in  industry  since  we  entered  the  war 
and  that  the  large  percentage  of  these  fractures  were  due  to  faulty 
shoes.  He  had  just  inspected  700  women  workers  in  one  factory 
and  only  fifteen  of  these  were  wearing  shoes  with  a  low,  common  sense 
heel. 

42  657 


658  INDUSTRIAL    MEDICINE    AND    SURGERY 

The  minor  foot  ailments  which  result  from  wearing  the  wrong 
type  of  shoes  not  only  cause  an  actual  loss  of  time  from  work  but 
result  in  a  mental  and  physical  attitude  on  the  part  of  the  affected 
employees  which  materially  decreases  their  efficiency.  Such  people 
are  uncomfortable  and  cross  and  their  mind  is  on  their  painful  feet 
more  than  on  their  work.  Their  speed  is  slowed  up  and  they  must 
frequently  sit  down  and  rest.  Driven  to  despair,  they  try  to  operate 
on  a  corn  or  ingrown  toe-nail  or  to  open  a  blister  and  as  a  result 
infections  often  develop.  Many  cases  of  prolonged  disabihty  from 
infections  following  these  self-attempted  operations  have  been  seen  by 
every  surgeon  in  industry. 

It  is  quite  obvious,  therefore,  that  more  attention  must  be  paid 
to  the  shoes  worn  by  employees.  Now  is  the  logical  time  to  persuade 
all  men  to  adopt  a  shoe  similar  to  the  Munson  last  used  in  the  army. 
A  shoe  made  along  these  same  lines  for  all  men  workers  should  be 
strongly  advocated.     A  nation-wide  educational  campaign,  pointing 


Fig.   187. — Illustrating  foot  resting  on  the  two  sides  of  a  concave  inner  sole  without 
support  to  the  transverse  arch.     (Rugh,  in  Journal  A.  M.  A.) 

out  the  advantages  to  both  health  and  efficiency  gained  by  wearing 
proper  shoes  is  certainly  indicated  and  the  surgeons  in  industry  are 
in  position  to  take  the  lead  in  such  a  campaign. 

The  little  book  entitled  "The  Soldier's  Foot"  by  Colonel  Munson, 
M.  C,  U.  S.  A.,  should  be  the  guide  of  every  surgeon  in  advising  his 
patients  regarding  the  proper  care  of  the  feet. 

The  Munson  last  is  a  wider  shoe  at  the  toe  than  is  normally  worn 
by  civiHans.  As  a  result  the  toes  are  not  cramped  and  the  muscles 
of  the  foot  have  freer  play,  and  rooin  to  develop  and  strengthen. 
When  properly  fitted,  there  is  about  two-thirds  of  an  inch  between  the 
longest  toe  and  the  end  of  the  shoe.  The  heel  is  held  firmly  in  the 
shoe  and  the  forefoot  fits  snugly  against  the  vamp.  The  ball  of  the 
foot  rests  securely  in  its  seat  near  the  posterior  turn  of  the  sole.  The 
sole  is  shghtly  convex,  conforming  to  the  concavity  of  the  foot, 
instead  of  being  a  concave  sole  as  is  usually  the  case  with  so  many 
of  the  shoes  worn  by  working  men  and  women.  Fig.  187  shows  the 
lack  of  support  to  the  transverse  arch  afforded  by  such  shoes. 


THE    employee's    FOOT  .  659 

Many  conditions,  especially  corns,  callosities,  blisters  and  early 
signs  of  flat-foot  will  disappear  when  the  feet  are  fitted  with  the 
proper  shoes,  for  instance  this  Munson  last. 

In  examining  applicants  for  work  and  in  examining  old  employees 
the  physician  in  industry  should  always  examine  the  shoes,  as  well 
as  the  condition  of  the  feet.  Tactfully  the  socks  should  likewise 
be  examined  and  vvhen  dirty  or  containing  holes  or  too  short,  instruc- 
tions concerning  the  proper  type  of  sock  should  be  given.  When 
ill-fitting  shoes  are  worn  the  dangers  from  the  same  should  be  pointed 
out  and  the  proper  type  recommended.  Such  employees  should  be 
re-examined  to  ascertain  whether  the  recommendations  have  been 
followed.  Just  as  in  the  case  of  eye  conditions  or  bad  teeth  so  should 
the  feet  receive  the  same  attention  and  when  necessary  loans  should 
be  advanced  by  the  Employees  Service  Department  for  the  obtaining 
of  proper  shoes,  as  is  done  for  the  buying  of  proper  glasses. 

Foot  disabilities  are  so  common  that  few  concerns  could  afford 
to  reject  such  cases  for  employment  and,  in  fact,  such  a  course  would 
work  great  injustice,  but  the  efficiency  of  the  working  force  can  be 
maintained  at  a  higher  standard  if  careful  selection  of  jobs  is  made 
for  such  people.  Employees  with  the  following  defects  should  always 
be  assigned  to  the  sedentary  occupations,  where  foot  power  is  not 
so  essential:  (1)  flaccid  flat  feet,  with  marked  abduction  or  eversion; 
(2)  arched  or  spastic  flat  feet;  (3)  disabling  arthritic  conditions 
following  trauma  or  disease;  (4)  marked  callosities;  (5)  certain  deformi- 
ities  following  fracture,  as  pes  varus  or  valgus;  (6)  painful  bunions  or 
extreme  and  painful  hallux  valgus;  (7)  weak  feet,  from  partial  ampu- 
tations or  severe  derangements  of  the  joints,  especially  of  the  great 
toe;  (8)  painful  heel  when  due  to  exostosis  of  the  under  surface  of  the 
OS  calcis. 

When  employees  are  affected  by  any  of  the  following  foot  con- 
ditions corrective  measures  can  be  instituted  that  will  make  most 
workmen  fit  and  efficient  for  practically  any  type  of  employment: 
(1)  flat  feet  without  much  abduction  or  eversion;  (2)  less  marked 
pathologic  conditions  which  apparently  have  existed  for  years  with- 
out evident  trouble ;  (3)  weak  and  poorly  developed  feet  without  patho- 
logic defects;  (4)  hallux  valgus,  uninflamed  bunions,  mild  claw  toes, 
hammer-toes  and  ingrown  toe-nails;  (5)  corns,  blisters,  callosities, 
etc.  Employees  with  such  conditions  can  usually  be  reheved  by 
properly  fitted  shoes,  by  alterations  of  the  shoes,  as  inserting  a 
wedge  along  the  inner  sole  and  by  such  minor  operations  as  may  be 
indicated.  Such  relief  is  certainly  within  the  province  of  industrial 
surgery. 

Symptoms  arising  from  foot  ailments,  especially  in  cases  of  flat 
feet,  are  often  not  limited  to  the  extremities  alone.     Pain  in  the  ankles 


660  INDUSTRIAL    MEDICINE    AND    SURGERY 

and   calves   is  very   common;  sciatica  is  frequently  complained  of  and 
is  usually  relieved  by  correction  of  the  foot  trouble. 

These  symptoms,  in  addition  to  affecting  the  working  abihty, 
frequently  give  rise  to.  claims  for  compensation.  Often  the  pain  in  the 
back,  or  the  sciatica  is  blamed  on  a  strain  in  lifting,  a  fall  or  the 
result  of  jumping  from  a  ladder  or  platform.  Therefore,  it  is  very 
important  from  a  medicolegal  standpoint  to  examine  every  employee's 
feet,  to  note  every  pathologic  condition  and  the  symptoms  which  may 
arise  from  the  same,  and  to  make  careful  records  concerning  these.  In 
the  author's  experience,  in  at  least  six  cases  excessive  claims  for  damage 
have  been  refuted  because  these  employees'  records  showed  the 
pathologic  foot  condition  to  have  existed  to  practically  the  same 
degree  at  the  time  of  their  employment. 

TREATMENT  OF  SPECIFIC  CONDITIONS 

Corns. — These  are  locaUzed  callosities  of  the  skin  of  the  foot  and 
are  due  to  continued  pressure  or  injury  from  ill-fitting  shoes.  The 
first  step  in  curing  corns  is  to  remove  their  cause.  Therefore,  cor- 
rection of  the  shoes  is  the  first  essential.  The  commonest  palHative 
treatment  is  to  shave  or  pare  the  corn  but  this  gives  temporary  rehef 
only.  After  we  began  to  pay  considerable  attention  to  corns  in  the 
surgical  dispensary  great  numbers  of  these  cases  reported.  The 
routine  treatment  consisted  of  the  following: 

1.  For  small  external  corns  and  small  internal  corns  a  small  strap 
of  adhesive  plaster  was  applied  tightly  over  the  affected  area.  This 
was  worn  for  a  week,  at  the  end  of  which  time  the  employee  reported 
again  and  the  plaster  was  removed.  The  corn  was  usually  so  softened 
that  the  doctor  could  readily  remove  it  without  any  bleeding.  After 
removal  iodin  was  applied.  If  necessary,  the  adhesive  plaster  treat- 
ment was  continued  for  two  or  three  weeks.  Naturally  the  shoes  were 
corrected  in  every  case. 

2.  For  large  corns,  callosities  and  the  large  soft  corns  (those 
between  toes)  a  corn  salve  was  applied  consisting  of  the  following : 

Salicylic  acid 40  parts 

Vaselin 30  parts 

Lanolin 30  parts 

This  ointment  is  smeared  immediately  over  the  corn  and  covered 
with  a  strip  of  zinc  oxid  plaster.  These  cases  are  given  a  small  amount 
of  the  ointment  and  instructed  to  soak  the  foot  in  warm  water  every 
night  and  apply  it  as  above  described.  After  the  fourth  application 
the  employee  reports  to  the  doctor  who  is  then  able  to  remove  the 
softened  corn,  usually  without  any  sign  of  bleeding.  The  area  is 
touched  with  iodin  and  if  a  small  area  of  the  corn  or  callosity  remains 


THE    employee's    FOOT  661 

adhesive  plaster  is  again  applied  and  usually  after  three  or  four  days 
can  be  removed  and  the  corn  has  disappeared. 

Callosities. — Callosities  are  enlarged  corns,  usually  appearing  on 
the  soles  of  the  feet,  especially  at  the  base  of  the  second  toe.  They 
are  often  indicative  of  a  broken  transverse  arch  and  usually  accompany 
the  condition  known  as  Morton's  toe.  They  also  appear  over  the  tops 
of  toes  in  marked  claw  feet  or  in  the  condition  known  as  hammer-toe. 
Again  they  may  appear  over  a  bunion.  These  large  callosities  fre- 
quently give  rise  to  considerable  pain  and  cause  much  disability. 

They  are  treated  as  described  for  corns.  Shoes  with  correction  of 
flattening  of  the  transverse  arch  are  necessary  for  the  complete  cure. 
Various  types  of  pads  and  arch  supports  are  sold  for  this  condition 
but  a  cleat  of  leather  one-eighth  of  an  inch  thick  and  one  inch  wide,  fas- 
tened to  the  sole  of  the  shoe  just  back  of  the  metatarsal  heads  is  the 
most  practicable  support.  This,  combined  with  proper  toe  exercises, 
will  usually  restore  the  function  in  this  arch. 

Blisters  and  Abrasions. — These  commonly  result  from  the  wear- 
ing of  large  size  shoes  and  the  constant  rubbing  of  the  same  on  the 
part.     They  are  most  commonly  located  on  the  heel. 

These  should  be  painted  with  iodin,  pierced  at  their  lowest  border 
and  after  the  fluid  has  been  removed,  strapped  firmly  with  zinc  oxid 
plaster.  Abrasions  may  first  be  treated  with  some  soothing  powder, 
such  as  bismuth  subnitrate  and  then  covered  with  the  adhesive  plaster. 

Fissures. — Cracks  or  fissures  of  the  skin  between  the  toes  and  on 
the  soles  of  the  feet  are  rather  common  among  employees  engaged  in 
heavy  work  in  hot  places  and  who  are  constantly  on  their  feet.  They 
are  usually  quite  painful  and  tend  to  bleed.  Very  serious  infections 
have  occurred  from  these  fissures. 

The  feet  should  be  washed  and  dried  thoroughly,  rubbed  with  al- 
cohol and  dusted  over  with  boric  powder  or  bismuth  subnitrate,  or 
even  with  talcum  powder.  Cauterizing  of  the  fissures  with  silver 
nitrate  once  or  twice  will  assist  in  the  cure.  After  this  treatment  they 
may  be  covered  with  adhesive  plaster. 

Sweaty  Feet. — This  is  a  very  common  afiiiction  among  working 
men  and  causes  great  loss  in  their  efficiency  and  may  result  in  actual 
disabihty.  As  a  result  of  the  sweating  the  skin  on  the  sole  and  be- 
tween the  toes  becomes  soft,  whitish  and  dead  looking  and  bhsters 
and  abrasions  form  very  easily.  Such  a  condition  is  usually  the  sign 
of  falling  arches  and  its  cure,  therefore,  implies  the  toning  up  of  the  foot 
by  proper  exercises. 

Frequent  bathing  of  the  feet,  changing  the  socks  almost  daily  and 
disinfecting  the  shoes  are  absolutely  necessary  for  continued  cure. 
The  employee  should  be  given  a  solution,  containing  formalin  }4,  per 
cent.,  choral  hydrate  3  per  cent.,  and  instructed  to  rub  this  on  the  feet 


662  INDUSTRIAL   MEDICINE    AND    SURGERY 

every  night  after  bathing  them  in  very  hot  water.  This  should  be  ap- 
plied with  a  cloth  as  it  may  cause  drying  and  cracking  of  the  hands. 
No  more  important  preventive  work  can  be  carried  on  in  the  plant 
dispensary  than  this  correction  of  sweaty  feet. 

If  bromidrosis  is  present,  or  results  after  the  above  treatment,  the 
condition  should  be  treated  by  bathing  in  hot  water  followed  with 
cold  and  then  the  foot  should  be  rubbed  with  olive  oil. 

Ingrowing  Nails. — This  condition,  most  common  in  the  great  toe, 
consists  of  an  inward  curving  of  the  nail  which  then  grows  down  into 
the  flesh.  Pain  is  often  marked  and  the  employee  usually  tries  to 
relieve  the  condition  by  cutting  away  the  nail.  Infection  is  very  fre- 
quent and  a  chronic  suppurative  condition  may  persist  for  months 
about  the  imbedded  nail.  I  have  seen  one  case  of  general  arthritis 
in  which  the  entire  body  was  unsuccessfully  searched  for  the  focus  of 
infection  by  the  attending  physician,  when,  after  about  two  weeks 
the  interne  discovered  a  low-grade  suppurative  condition  about  an  in- 
grown toe-nail.  Curing  of  this  condition  resulted  in  recovery  from 
the  arthritis.  Many  cases  of  severe  infection  occur  from  ingrown  toe- 
nails. Such  a  condition  is  caused  by  pressure  of  the  socks  or  shoes, 
combined  with  improper  trimming  of  the  nail. 

The  toe-nail  must  be  trimmed  squarely  across.  In  mild  cases  raise 
the  edge  of  the  nail  with  a  sterilized  probe  and  insert  a  small  pledget 
of  cotton.  By  reinserting  larger  pledgets  daily  the  nail  may  be  forced 
away  from  the  flesh.  In  the  more  serious  cases  or  where  infection 
is  present  a  local  anesthetic  of  3^^  per  cent,  novocain  should  be  injected 
and  the  outer  quarter  of  the  nail  removed  completely  to  its  base, 
lodin  sterilization  must  precede  this  operation  and  should  also  be  ap- 
plied afterwards.  Apply  hot  dressings  for  twenty-four  hours  in  case  of 
infection.  Subsequent  dressings  may  consist  of  white  precipitate  oint- 
ment covered  with  a  small  piece  of  sterile  dressing,  held  in  place  by  adhe- 
sive plaster. 

Hallux  Valgus  or  Bunions. — These  are  usually  the  result  of  faulty 
shoes.  The  transverse  arch  is  flattened  in  a  majority  of  the  cases.  The 
condition  consists  of  a  deflection  of  the  great  toe  toward  the  outer  side 
of  the  foot,  with  an  enlargement  (exostosis)  of  the  lateral  aspect  of 
the  joint. 

Mild  cases  will  usually  improve  by  the  use  of  a  proper  shoe,  such 
as  the  Munson  last.  In  case  the  bunion  is  irritated  a  bunion  ring  di- 
vided in  half  and  placed  just  back  of  the  point  of  irritation  to  pro- 
tect rubbing  from  the  shoe  and  held  in  place  with  adhesive  plaster 
gives  great  relief.  When  the  entire  bunion  ring  is  applied  that  portion 
in  front  of  the  bunion  tends  to  increase  the  deflection  of  the  toe  and, 
therefore,  should  never  be  used.  In  serious  cases,  one  of  the  classical 
bunion  operations  should  be  performed.     The  best  operation  consists 


THE    employee's    FOOT  663 

of  the  removal  of  the  exostosis,  combined  with  the  removal  of  a  wedge- 
shaped  piece  of  bone  from  the  proximal  end  of  the  phalanx,  which  is 
then  given  the  proper  concavity  required  for  articulation.  This  is 
not  an  operation  suitable  for  the  plant  dispensary  but  should  be  per- 
formed at  the  hospital. 

Hammer-toe. — This  deformity,  usually  of  the  second  toe,  con- 
sists of  a  contracture  in  dorsal  flexion  at  the  metatarsal  phalangeal 
joint  accompanied  by  "contracture  at  the  plantar  flexion  at  the  prox- 
imal interphalangeal  joint."  A  corn  or  callosity  forming  on  top  of 
the  toe  usually  causes  great  distress  and  much  disability. 

This  condition  can  practically  always  be  cured  without  amputa- 
tion, which  should  be  condemned  as  it  leaves  the  foot  in  a  weakened 
condition.  Tenotomy  of  the  extensor  tendon  just  back  of  the  meta- 
tarsal phalangeal  joint  will  usually  permit  the  straightening  of  the  toe. 
When  necessary  a  wedge-shaped  piece  of  bone  with  the  base  upward 
can  be  removed  from  the  interphalangeal  joint.  After  the  operation 
a  small  splint  is  applied.  This  can  be  made  from  a  tongue  depressor. 
Deformities  of  the  little  toe,  similar  to  the  above,  are  very  common 
and  should  be  treated  in  the  same  way. 

Foot  Strain. — This  is  commonly  seen  in  those  cases  described  as 
"flat-foot."  It  may  be  of  the  acute  variety  where  the  condition  of 
the  foot  strain  occurs  without  any  pathologic  change  in  the  arches 
of  the  foot.  Such  a  condition  is  common  among  employees  who  have 
been  transferred  from  sedentary  work  to  occupations  keeping  them 
constantly  on  their  feet  and  especially  when  this  is  accompanied  with 
carrying  of  loads.  It  is  characterized  by  severe  pain  and  the  foot  may 
become  swollen. 

Chronic  foot  strain  is  usually  accompanied  by  changes  in  the  arches 
or  other  pathologic  change  in  the  foot.  The  three  commonest  types 
are:  (1)  flaccid  feet  with  flattening  of  the  longitudinal  arch;  (2)  rigid 
feet,  usually  following  arthritic  changes,  such  as  adhesions  and  peri- 
articular infiltrations.  When  occurring  in  a  single  foot  it  must  be 
differentiated  from  tuberculosis  of  the  joints  or  bones  of  the  feet.  An 
a:-ray  examination  in  doubtful  cases  should  always  be  made;  (3)  spas- 
tic feet,  which  are  usually  due  to  a  definite  spasm  of  the  peroneal  group 
of  muscles;  (4)  osseous  flat-foot,  a  condition  in  which  bony  changes 
have  occurred  after  the  arches  have  fallen,  resulting  in  a  rigid  type  of 
feet. 

Treatment  of  the  acute  foot  strain  consists  of  rest,  strapping  of  the 
foot  with  adhesive  plaster  and  a  gradual  return  to  the  work  causing 
the  condition. 

Ordinary  flat-foot  is  usually  treated  by  the  use  of  plates  or  supports 
worn  within  the  shoe.  They  can  best  be  treated,  however,  by 
strapping  the  foot  with  adhesive  plaster,  as  illustrated  in  Figs.  188,  189, 


664 


INDUSTRIAL    MEDICINE    AND    SURGERY 


190,  191,  192,  193,  and  by  suitable  alterations  in  the  shoes.  The  best 
alteration  is  a  simple  wedge  of  leather,  Y4.  of  an  inch  thick  and  tapering 
to  3^  of  an  inch,  placed  between  the  layers  of  the  sole  and  heel  along 
the    entire   length  of  the  inner   side  of  the  shoe.     Combined  with 


Fig.   188. — Strapping  of  the  foot.     Application  of  the  first  strip,  seen  from  the  outer 
side.      {From  Medical  War  Manual  No.  4,  "Military  Orihopcedic  Suroery.") 

these   changes  suitable  foot  exercises  should  be  given,  such  as  the 
following : 

1.  Stand  with  feet  parallel;  roll  them  outward,  standing  on  the 
outer  border;  rise  on  the  outer  borders  without  twisting  the  legs  or 
bending  the  knees;  walk  in  this  position. 


Fig.   189. — Application  of  the  first  strip,  seen  from  the  inner  side.      (From  Medical  War 
Manual  No.  4,  "Military  Orthopasdic  Surgery.") 

2.  Stand  on  a  walk  or  thick  board,  toes  overhanging  the   edge. 
Bend  the  toes  over  as  far  as  possible,  repeating  several  times. 

3.  Exercise  the  bare  feet  by  walking  on  a  board  tapering  from  the 
center  to  the  edges  by  a  35  degree  angle.     Employees  with  flat  feet, 


THE    EMPLOYEE  S    FOOT 


665 


forced  to  stand  all  day  should  be  provided  with  such  a  board  which 
they  can  stand  on  at  intervals  several  times  a  day. 

The  rigid  type  of  foot  should  be  converted  into  the  flaccid  type  by 
the  use  of  alternating  baths  and  massage  repeated  daily.     If  the 


Fig. 


190. — Application  of  the  second  strip,  seen  from  the  outer  side. 
War  Manual  No.  4,  "Military  Orthopcedic  Surgery.''') 


{From  Medical 


rigidity  is  more  marked  it  may  be  necessary  to  adopt  forcible 
manipulation  under  anesthesia.  After  the  condition  has  become 
flaccid  it  can  be  treated  as  described  above  or  in  the  more  serious  cases 
it  may  be  necessary  to  apply  plaster-of-Paris  dressings. 

In  the  spastic  type  it  is  often  necessary  to  resort  to  tenotomy  of 


.. .....I 

,  ■'  ■  ■■■I^a5^ 

Fig.   191. — Application  of  the  second  strip,  seen  from  the  inner  side. 
War  Manual  No.  4,  "Military  Orthopcedic  Surgery.") 


{From  Medical 


the  peroneal  group  of  muscles  in  order  to  convert  this  into  the  flaccid 
type,  after  which  the  treatment  consists  of  holding  the  foot  in  the 
position  of  supination  and  adduction  for  three  or  four  weeks  by  means 
of  plaster-of-Paris  casts.     After  this,  strapping  of  the  foot,  proper  foot 


666  INDUSTRIAL    MEDICINE    AND    SURGERY 

exercises  and  alterations  of  the  shoes  must  be  carried  out  until  recovery- 
is  complete. 

These  conditions  of  the  feet,  which  are  commonly  considered  as 
belonging  to  the  round  of  orthopedic  surgery  must  receive  the  most 


Fig.  192. — Completed  dressing,  seen  from  the  outer  side.     {From  Medical  War  Manual 
No.  4,  "Military  Orihopcedic  Surgery.") 

careful  consideration  of  every  industrial  surgeon.  He  should  not 
consider  himself  qualified  for  his  position  until  he  has  completely 
learned  the  various  orthopedic  methods  necessary  to  overcome  this 


Fig.   193. — Completed  dressing,  seen  from  the  inner  side.      (From  Medical  War  Manual 
No.  4,  "Military  Orthopaedic  Surgery.") 

type  of  disabihty,  which  has  been  such  a  source  of  financial  loss  to 
both  the  employee  and  employer.  This  short  resume  concerning  the 
care  of  foot  conditions  is  given  in  order  to  stimulate  surgeons  in  in- 
dustry to  meet  this  great  responsibility. 


Part  V 

COMPENSATION.    INSURANCE.    MEDICO- 
LEGAL PHASES 


CHAPTER  XLI 

EMPLOYEES'  COMPENSATION  FROM  THE  MEDICAL 
VIEWPOINT 

In  1911,  the  first  Employees'  Compensation  Act  was  passed.  Since 
that  time  37  of  the  48  States  of  the  Union  have  adopted  similar  laws. 
The  rapid  spread  of  this  principle  of  compensation,  so  closely  related 
to  health  insurance,  has  inaugurated  a  form  of  sociahzed  medicine 
which  is  bound  to  extend  into  other  fields. 

In  the  states  where  the  compensation  acts  are  best  administered, 
the  "shyster  lawyers"  commonly  known  as  the  "ambulance  chasers," 
no  longer  carry  on  their  nefarious  trade.  Likewise  the  so-called  pro- 
fessional "expert  witness"  who  sells  his  medical  testimony  to  the 
highest  bidder,  is  becoming  less  and  less  a  frequenter  of  our  courts. 

Employees'  compensation  has  stimulated  the  growth  of  industrial 
medicine  and  surgery  more  than  any  other  one  thing.  Employers 
have  come  to  reaHze  that  the  human  body  is  a  most  expensive  machine 
and  must  be  cared  for  and  kept  in  good  repair.  Most  of  these  laws  are 
based  upon  the  theory  that  one  is  bound  by  the  natural  consequences 
of  his  acts.  Therefore,  if  an  employer  hires  a  defective  workman,  as 
for  example,  a  man  blind  in  one  eye,  who  later  meets  with  an  accident 
during  the  course  of  his  employment  and  is  totally  disabled  thereby, 
for  instance,  the  loss  of  the  other  eye  resulting  in  total  bhndness,  the 
employer  is  held  responsible  for  this  total  disability.  This  has  caused 
many  concerns  to  establish  a  system  of  medical  examination  of  em- 
ployees, especially  applicants  for  work,  in  order  to  reduce  the  number 
of  compensable  cases.  Such  a  plan  naturally  has  worked  many  hard- 
ships upon  handicapped  individuals  seeking  employment.  Fortunately 
most  industries  to-day  take  a  broader  viewpoint  of  this  work,  and  have 
made  these  medical  examinations  a  definite  part  of  the  medical  super- 
vision of  employees.  Such  handicapped  men  are  employed  on  jobs 
where  they  can  still  be  efficient  and  where  accident  hazards  do  not 

667 


668  INDUSTRIAL    MEDICINE    AND    SURGERY 

exist  for  them.  In  many  states,  however,  industries  are  still  dis- 
criminating against  those  workers  who  are  unfortunate  enough  as  to 
have  physical  defects,  with  the  result  that  man-power  in  this  country  is 
not  being  used  as  it  should  be. 

The  prevention  of  accidents  is  now  an  established  fact  and  is  due 
in  a  large  measure  to  the  compensation  principles. 

State  compensation  boards  are  constantly  emphasizing  to  em- 
ployers the  importance  of  engaging  only  expert  surgeons.  Even 
though  the  initial  cost  is  greater  yet  the  quicker  recoveries  and  the 
better  functional  results  materially  decrease  the  ultimate  expense. 
One  large  insurance  executive  recently  said,  '^  Maximum  surgical  care 
gives  a  minimum  of  bad  results." 

Mr.  Charles  F.  Andrus,  Chairman  of  the  Illinois  Industrial  Com- 
mission elucidates  this  point  by  saying:  '^The  Medical  Directors  of 
the  Commission  can  do  much  to  assist  in  encouraging  employers  to 
procure  the  proper  kind  of  medical  treatment.  They  may  be  shown 
that  there  is  nothing  more  costly  than  cheap  medical  work.  The 
experience  of  one  large  firm  in  Chicago  with  their  medical  department 
illustrates  it.  This  Company  was  paying  their  medical  head  $75  per 
month  and  imagined  they  were  saving  money.  They  concluded  to 
change  their  system  and  put  a  trained  surgeon  in  charge.  The  first 
year  the  medical  expense  increased  800  per  cent.  In  the  preceding 
year  this  company  had  had  31  law  suits.  In  the  first  year  of  the  new 
system  they  had  one  suit  and  the  Claim  Department  saved  $30,000. 
This  was  accomplished  in  several  ways.  Regardless  of  expense,  the 
men  would  get  the  proper  kind  of  medical  treatment  and  they  were  able 
to  return  to  work  sooner.  The  medical  chief  told  the  men  the  exact 
truth  about  their  conditions  and  did  not  act  as  a  sounding  board  for 
the  claim  agent.  The  consequences  were  that  the  men  had  confidence 
in  him  and  the  ambulance  chasers  did  not  succeed  in  stirring  up  trouble. 
They  were  ready  to  make  a  settlement  on  what  the  physician  told 
them  as  they  knew  he  was  telling  the  truth.  Taking  into  consider- 
ation, aside  from  the  actual  money  saved,  the  increase  of  good  feeling 
between  the  employer  and  the  employee  which  is  so  necessary  in 
modern  industrial  times,  it  may  be  readily  seen  that  cheap  medical 
treatment  does  not  pay." 

The  Industrial  Accident  Commission  of  California  in  their  1918 
report,  states  in  this  connection,  as  follows:  "The  Company  with  the 
closest  personal  scrutiny  by  its  medical  chief  and  the  highest  type  of 
medical  men  to  do  the  work,  seems  to  obtain  the  cheapest  and  best 
medical  results." 

The  establishment  of  many  surgical  dispensaries  in  industry  has 
followed  in  the  wake  of  the  compensation  acts.  For  several  years  a 
few  prominent  surgeons  have  advocated  the  principle  that  the  greatest 


EMPLOYEES  COMPENSATION 


669 


safety  precaution  for  an  injured  employee  is  the  immediate  care  of  his 
wound  by  a  competent  surgeon.  In  order  to  accomphsh  this  it  is 
necessary  to  introduce  surgery  directly  into  industry.  Here  again 
quotation  from  the  California  Commission  is  pertinent:  "Frequently 
the  course  of  a  surgical  case  is  determined  by  the  first  treatments. 
This  leads  to  the  thought  that  to  obtain  the  best  surgical  results  in 
accident  cases,  the  injured  must  fall  into  the  hands  of  a  competent 
surgeon  with  the  least  possible  delay.  Furthermore,  it  leads  to  the 
thought  that  unless  a  doctor  is  qualified  to  do  major  surgery  he  should 
not  attempt  to  handle  a  major  surgical  case,  except  in  emergency,  and 


Fig.  194. — The  greatest  safety  measure  for  an  injured  employee  is  immediate, 
competent  surgical  care.  Prompt  attention  to  eye  injuries  in  this  plant  dispensary 
has  reduced  blindness. 


if  he  is  not  able  to  handle  major  surgery  or  to  perform  major  surgical 
operations  he  is  ill  equipped  to  make  surgical  diagnosis  or  even  to 
recognize  major  surgical  conditions.  The  minor  surgical  case  fre- 
quently develops  into  a  major  case.  The  less  skillful  the  surgeon  the 
more  frequently  this  happens." 

Now  that  some  states  are  including  certain  occupational  diseases 
among  the  compensable  conditions,  industries  are  being  stimulated  to 
employ  expert  physicians  in  order  to  discover  these  diseases  early  and 
to  establish  a  proper  preventive  program  against  them. 

Thus  it  is  quite  evident  that  the  employees'  compensation  legislation 
in  this  country  has  advanced  industrial  medicine  and  surgery  at  least 


670  INDUSTRIAL    MEDICINE    AND    SURGERY 

a  generation.  It  can  be  irrefutably  assumed  that  if  compensation  was 
extended  to  include  all  sickness,  as  proposed  in  health  insurance,  it 
would  not  only  advance  industrial  medicine  but  all  medical  practices. 
In  fact,  a  beneficent  system  of  socialized  medicine  would  rapidly  ensue. 
The  best, plan  of  accident  compensation  has  existed  in  a  few  in- 
dustries even  prior  to  the  Compensation  Act.  This  is  based  upon  the 
humanitarian  principle  that  the  employer  is  completely  responsible 
for  the  results  of  all  accidents  occurring  to  employees  during  the  course 
of  their  employment.  Such  a  concern  considers  the  repair  and 
restoration  of  the  injured  employee  a  moral  and  economic  responsi- 
bihty  just  as  much  as  the  repair  of  a  broken  machine.  Therefore, 
prevention  of  accidents,  the  best  kind  of  medical  treatment,  no  matter 
what  the  expense,  the  complete  rehabihtation  of  all  injured,  and  their 
re-employment  in  suitable  work  is  definitely  included  in  their  compen- 
sation program.  If  the  injured  employee  is  deprived  of  his  earning 
power  because  of  the  accident  these  concerns  agree  that  he  should  go  on 
receiving  his  full  wages  the  same  as  though  he  was  working. 

Such  a  pohcy  as  the  above  is  broader  and  more  equitable  than  any 
compensation  law  thus  far  imposed  upon  industry.  Naturally,  a 
concern  governed  by  this  moral  responsibiHty,  exacting  as  it  does 
greater  compensation  than  is  legally  required,  is  forced  to  carry  its 
own  insurance.  These  employers  give  the  workman  the  benefit  of  the 
doubt  and  never  quibble  over  legal  technicalities  involved  in  the  settle- 
ment, as  so  often  happens  when  an  insurance  company  is  making  the 
settlement. 

The  author  had  the  privilege  of  working  for  such  a  broad-minded 

industry.     During  the  period  of  nine  years,  only  six  cases  were  carried 

to  the  courts  for  settlement.     In  two  of  these,   compensation  was 

refused  by  the  court  because  the  concern  was  not  responsible  for  the 

accident;  in  the  third,  compensation  was  refused  because  the  disabihty 

was  due  to  a  diseased  condition  and  not  to  the  coincidental  accident; 

and  in  the  other  three,  the  claimants  were  proven  to  be  mahngerers. 

This  does  not  mean  that  all  injured  employees  were  given  a  money 

settlement,  for  many  claimed  damages  who  did  not  deserve  them. 

But  both  the  manager  and  the  medical  staff  gained  the  reputation 

throughout  the  working  force  of  giving  a  square  deal  to  all.     This 

greatly  facilitated  the  handhng  of  these  cases.     When  a  concern  adopts 

this  pohcy  it  is  practically  compelled  to  employ  its  own  medical  staff. 

If  the  care  of  the  injured  employee  is  left  to  disinterested  surgeons  the 

loss  of  time  from  work  usually  is  increased.     Again  if  the  employee 

loses  the  personal  touch  with  the  management  he  is  hable  to  become 

dissatisfied   and   dissatisfaction  is  the  commonest  cause  for  damage 

suits.     On  the  other  hand,  the  medical  staff  of  the  industry  takes  a 

personal  interest  in  the  employees  and  they  in  turn  develop  great  con- 


employees'  compensation  671 

fidence  in  the  doctors.  The  company  surgeon,  as  the  representative 
of  the  management,  is  best  able  to  encourage  the  injured  man  and  to 
allay  his  fears  regarding  his  rights  and  his  future  opportunities  for 
employment  with  the  concern.  They  are  able  to  "counteract"  the 
effect  of  the  pernicious  activity  sometimes  displayed  by  well-meaning 
friends.  Thus,  by  having  their  own  medical  staff  such  an  industry 
saves  the  time  loss  and  the  ensuing  expense,  as  well  as  the  expense  of 
a  great  number  of  settlements.  The  money  saved  in  this  way  can  be 
used  to  pay  full  wages  to  the  injured  employees  for  the  entire  time  they 
are  disabled.  This  fair  treatment  on  the  part  of  the  management 
develops  loyalty  and  good  feeling  among  the  employees  which  also 
help  in  reducing  the  number  of  damage  suits.  There  is  no  question  in 
my  mind  but  that  this  system,  based  upon  the  moral  responsibility 
of  the  employer  toward  his  employees  is  by  far  the  most  economical 
plan  of  compensation  which  can  be  adopted  by  any  industry.  That 
the  medical  expense  is  also  reduced  is  borne  out  by  the  statement  of 
the  California  Commission  which  says,  "it  appears  that  employers 
who  carry  their  own  insurance  and  provide  their  own  medical  service 
show  the  lowest  medical  cost." 

A  resume  of  the  37  Workmen's  Compensation  Acts  in  this  country 
shows  many  variations  in  the  different  states.  There  are  23  states 
with  industrial  boards  or  commissions  to  administer  the  acts;  four 
states  each  have  a  single  commissioner;  and  in  ten  states  the  courts 
administer  the  acts.  In  23  of  the  states  the  compensation  is  paid 
either  directly  by  the  employer  or  by  the  insurance  company  indemni- 
fying him.  Nine  states  have  state-managed  insurance  funds  in  which 
the  employer  may  secure  a  policy  or  he  can  carry  his  insurance  in  one 
of  the  privately  owned  companies;  thus  the  state  has  entered  into 
competition  with  private  corporations.  In  only  five  states  is  the  fund 
from  which  the  compensation  is  paid  managed  completely  by  state 
insurance  boards.  In  these  five  states  the  rate  of  premium  is  fixed 
periodically,  usually  semi-annually,  and  depends  upon  the  number  of 
accident  cases  the  employer  has  had  during  the  preceding  year.  The 
premium  rate  in  many  of  the  privately  managed  insurance  companies 
is  also  dependent  upon  the  number  of  accidents  during  the  preceding 
year.  Naturally  the  rate  in  each  case  depends  to  a  large  extent  upon 
the  number  of  the  employees  and  the  hazards  of  the  occupations. 

In  some  states  claims  are  paid  on  the  order  of  the  court.  In  others 
they  are  paid  directly  from  the  state  fund  and  only  on  approval  of  the 
industrial  commission  and  in  a  third  class  settlements  are  made  as 
required  by  law  between  the  employer  and  the  injured  party  and  the 
claim  paid  direct  by  the  former,  only  the  disputed  cases  being  brought 
to  the  commission. 

The  amount  of  the  weekly  compensation  varies  from  one-half  to 


672  INDUSTRIAL   MEDICINE    AND    SURGERY 

two-thirds  of  the  wages  earned  by  the  injured  party.  Compensation 
comes  under  three  classes,  namely,  for  death,  for  total  disability  and 
for  .partial  disabihty.  In  addition  the  laws  in  the  majority  of  cases 
provide  for  medical,  surgical  and  hospital  attendance  and,  in  fatal 
injuries,  the  burial  expenses  as  well.  The  arguments  advanced  against 
the  payment  of  full  wages  during  the  time  of  disability  are  that  such 
a  plan  would  encourage  mahngering;  that  it  is  an  unjust  burden  thrown 
upon  the  employer  as  he  is  not  always  fully  responsible  for  the  accident; 
or  that  the  employee  being  a  definite  part  of  industry  must  share 
a  portion  of  the  wage  loss  following  an  accident.  It  would  seem  that 
these  arguments  overlook  the  fact  that  the  pain  and  inconvenience 
suffered  by  the  injured  workman  cannot  be  distributed  in  any  way 
to  the  employer;  neither  does  the  employer  share  the  additional  expense 
laid  upon  the  family  when  the  bread  winner  is  injured.  If  the  com- 
pensation acts  would  provide  a  more  equitable  weekly  compensation 
undoubtedly  a  reduction  in  the  number  of  claims  for  permanent 
disability  would  follow. 

Most  of  the  acts  fix  a  period,  known  as  the  "waiting  time"  during 
which  no  compensation  is  payable  immediately  following  the  injury. 
This  waiting  time  varies  with  the  different  states  from  six  days  to 
two  weeks,  although  most  of  the  states  pay  for  the  medical  and  surgical 
attendance  during  this  period.  In  a  few  states  when  the  disability 
is  prolonged  beyond  the  waiting  time  compensation  is  then  paid 
from  the  first  day  of  injury.  It  is  apparent  that  such  a  provision 
is  a  much  greater  temptation  for  mahngering  than  if  the  injured 
party  was  paid  full  wages  throughout.  Very  definite  proof  of  this 
fact  is  found  in  the  experience  of  the  Federal  Government,  as  set 
forth  in  the  Bulletin  of  Labor  Statistics  for  December,  1913.  "The 
Federal  statute  allows  no  compensation  for  an  injury  not  continuing 
for  more  than  15  days,  but  where  the  injury  continues  payment  is 
made  from  the  first  day.  This  results  in  the  denial  of  all  compensation 
for  disabihties  lasting  as  much  as  fourteen  days  or  fifteen  days,  but 
allowing  sixteen  days  full  pay  for  a  disabihty  of  a  single  day, 
or  portion  of  a  day,  beyond  the  waiting  time  fixed.  An 
amendment,  restricted  in  its  apphcation  to  the  Canal  Zone,  permits 
compensation  under  local  regulations  for  all  work  time  lost,  and  in 
connection  with  these  facts  it  may  be  noted  that  during  the  11  months 
of  1908-09,  that  this  law  was  in  operation,  55.2  per  cent,  of  all  injuries 
lasted  less  than  15  days  on  the  Canal  Zone,  while  in  all  the  other 
branches  of  the  service  the  number  was  40.95  per  cent,  of  the  total;  in 
1909-10,  61.4  per  cent,  of  the  injuries  on  the  Canal  Zone  terminated 
within  15  days,  while  in  the  other  branches  38.93  per  cent,  so  termi- 
nated; in  1910-11, 73.04  per  cent,  of  the  employees  on  the  Canal  Zone  re- 
covered in  less  than  15  days,  while  in  the  other  branches  of  the  service 


employees'  compensation  673 

the  number  amounted  to  but  39.35  per  cent."  During  this  same  period 
the  recoveries  from  disabihty  lasting  from  15  to  21  days  on  the  Canal 
Zone  during  the  three  years  1908-11  amounted  to  approximately 
10  per  cent,  of  the  whole  as  against  approximately  14  per  cent,  in 
all  other  branches  of  the  service  for  the  same  period.  Commenting 
upon  the  above  facts  the  Labor  Statistician  states  that  there  is  "  ground 
at  least  for  belief"  that  this  policy  in  the  Federal  Government  tended 
to  prolong  the  time  of  disability,  I  would  say  that  such  figures  ir- 
refutably prove  that  any  law  which  fixes  a  long  waiting  time  and  then 
provides  for  the  payment  of  compensation  for  the  full  period,  pro- 
viding the  disabihty  is  prolonged  beyond  the  fixed  time,  is  a  direct 
stimulus  for  a  certain  amount  of  malingering  and  even  tempts  the 
physician  to  abet  the  crime. 

It  is  very  essential  for  the  surgeon  in  industry  to  become  fully 
acquainted  with  the  different  compensation  acts  and  especially 
with  the  one  in  his  own  state.  Practically  every  year  the  Bureau 
of  Labor  Statistics,  Department  of  Labor,  issues  bulletins,  giving  a 
r^sum^  of  the  Workmen's  Compensation  Laws  in  the  United  States. 
These  are  an  invaluable  source  of  information  to  the  surgeon.  The 
National  Industrial  Conference  Board  in  April,  1917,  made  a  very 
exhaustive  study  of  the  various  acts  in  this  country  and  in  Great 
Britain  bearing  on  workmen's  compensation  and  issued  a  bulletin 
setting  forth  the  results  of  this  study.  The  following  quotation 
taken  from  this  report  gives  a  concise  statement  of  what  accidents 
and  diseases  are  included  in  the  various  acts: 

"Definitions  of  'Accident' — The  popular  conception  of  an  'accident' 
is  probably  much  narrower  than  the  definition  which  that  term  now 
receives  in  the  construction  of  compensation  legislation.  The  fact 
is  that  the  original  conception  has  been  greatly  modified  and  extended 
by  the  adoption  of  broader  statutory  language  and  by  administrative 
construction.  The  English  compensation  act,  which  served  as  a 
model  for  much  of  American  legislation,  created  its  fundamental 
liabihty  by  the  phrase  'personal  injury  by  accident  arising  out  of  and 
in  the  course  of  employment.'  That  phrase  is  identically  or  sub- 
stantially contained  in  the  acts  of  Arizona,  Colorado,  Indiana,  Kansas, 
Kentucky,  Louisiana,  Maryland,  Minnesota,  Nebraska,  New  Hamp- 
shire, New  Jersey,  Oklahoma,  Oregon,  and  Rhode  Island.  The 
quahfying  phrase  'by  accident'  is  omitted  in  the  remaining  acts, 
compensation  being  allowed  for  'personal  injury  arising  out  of  and  in 
the  course  of  employment,'  except  in  Ilhnois  and  Wisconsin,  where 
the  death  or  injury  is  sustained  'while  engaged  in  the  hne  of  his  duty 
as  such  employee, '  and  Maine,  Massachusetts,  Montana,  Ohio,  Texas, 
and  West  Viriginia,  which  omit  the  word  'accident'  and  qualify 
personal  injury  only  by  the  phrase  'in  the  course  of  his  emplojnnent.' 

43 


,674  INDUSTRIAL   MEDICINE    AND    SURGERY 

Washington  and  Wyoming  omit  the  word  'accident,'  the  former 
quahfying  the  term  'injury'  by  the  phrase  'resulting  from  some 
fortuitous  event  as  distinguished  from  the  contract  of  disease,'  the 
latter  using  the  phrases  'injury  sustained  in  extra  hazardous  employ- 
ment,' 'as  a  result  of  their  employment,'  'while  at  work  on  their 
employer's  prenxises  or  elsewhere  on  his  business. ' 

"  Effect  of  Modification. — The  effect  of  those  verbal  modifications 
of  the  parent  act,  the  broad  construction  of  which  already  permit- 
ted it  to  cover  many  forms  of  infection  by  disease  and  even  remote 
effects  of  injury,  has  been  to  greatly  extend  the  apphcation  of  the 
act,  from  what  are  popularly  considered  'accidents,'  to  many  forms 
of  sickness  and  to  liabihty  for  not  merely  the  torts,  but  the  crimes  of 
fellow-employees  and  third  persons  beyond  the  control  or  reach  of 
the  employer. 

"British  Definition  of  Accident. — The  term  accident  was  unsatis- 
factorily defined  in  the  first  English  compensation  act  of  1897,  in  the 
opinion  of  leading  commentators,  until  the  decision  by  the  House  of 
Lords  in  1903,  in  the  case  of  Fenton  v.  Thorley  and  Company 
(1903,  A.C.43).     In  that  case  Lord  MacNaghten  said: 

"'I  come,  therefore,  to  the  conclusion  that  the  expression  * '  accident ' ' 
is  used  in  the  popular  and  ordinary  sense  of  the  word  as  denoting  an 
unlooked-for  mishap  or  an  untoward  event  which  is  not  expected  or 
designed.' 

"  Separation  of  Accident  and  Disease  in  British  Acts. — In  a  further 
decision  of  the  House  of  Lords  in  the  case  of  Brinton's  Limited  v. 
Turvey  (1905,  A.  C.  230)  it  was  held  that  an  infection  to  the  eye  of 
a  workman  from  anthrax  in  the  wool  handled  by  him  was  'personal 
injury  by  accident.'  All  the  Law  Lords,  however,  took  occasion  to 
expressly  emphasize  their  view  that  the  decision  must  not  be  regarded 
'as  involving  the  doctrine  that  all  diseases  caught  by  a  workman  in 
the  course  of  his  employment  are  to  be  regarded  as  accidents.'  In 
the  succeeding  Enghsh  legislation  of  1906  compensation  was  allowed 
for  occupational  disease,  which  was,  however,  made  the  subject  of 
a  separate  statute  in  which  twenty-four  diseases  were  enumerated  and 
defined,  others  being  added  thereto  by  an  official  board  of  physicians 
upon  the  approval  of  the  Secretary  of  State. 

"American  Variations  of  Accident. — In  enacting  the  identical  or 
substantial  language  of  the  English  statute,  some  states  follow  it 
closely  as  in  Michigan,  narrow  it  somewhat  as  in  Nebraska,  where 
it  seems  to  require  extraneous  physical  injury,  or  as  in  New  York  con- 
strue it  even  more  liberally  through  the  Industrial  Commission, 
which  holds  it  to  be  a  compensable  accident  Avhen  a  street  railway 
process  server  dies  from  gangrenous  diabetes  alleged  to  result  from 
a  fellow-passenger  treading  upon  his  toes  while  the  decedent  was 


EMPLOYEES     COMPENSATION  675 

returning  to  his  place  of  employment  on  a  street  railway  car  of  the 
company  which  employed  him. 

"Proof  of  Accident. — The  occurrence  of  an  accident  is  generally 
held  to  be  a  mixed  question  of  law  and  fact,  but  its  meaning  when  ap- 
plied to  ascertain  facts  is  a  question  of  law. 

"Extension  of  Coverage  by  Massachusetts. — The  courts  of  Massa- 
chusetts point  out  very  clearly  the  extensive  increase  of  liability 
where  compensation  is  awarded,  as  in  that  state,  for  'personal  in- 
jur}'-'  as  distinguished  from  'personal  injury  by  accident.^  'There 
are  no  conditions,'  says  the  Supreme  Court  of  Massachusetts,  'which 
warrant  a  judicial  interpretation  of  the  phrase  "personal  injury" 
in  the  act  as  meaning  the  same  as  ''personal  injury  by  accident" 
or  as  excluding  from  the  scope  of  "personal  injuries"  those  instances 
where  a  diseased  physical  condition  may  have  invited,  or  rendered  the 
employee  unusually  susceptible  to  "personal  injury."'  The  word 
'injury'  in  the  Massachusetts  statute  will  include  whatever  lesion  or 
change  in  any  part  of  the  system  produces  harm  or  pain  or  a  lessened 
faculty  of  the  natural  use  of  any  bodily  activity  or  capacity. 

"Exclusion  of  Disease  by  Ohio,  Michigan,  Connecticut,  California 
and  Iowa. — Yet  the  Supreme  Courts  of  Ohio,  Michigan,  and  Connec- 
ticut have  held  that  'personal  injury,'  'even  without  the  qualifying 
word  "accident,"'  excludes  occupational  disease,  the  administrative 
boards  of  California  and  Iowa  reaching  the  same  conclusion  with  re- 
spect to  the  same  language, 

"  The  Massachusetts  View. — The  Massachusetts  Supreme  Court 
holds  to  the  contrary,  including  lead  poisoning  as  personal  injury, 
and  the  Wisconsin  Court  holds  typhoid  fever  contracted  from  drink- 
ing water  supplied  by  the  employer  to  be  a  'personal  injury.'  It 
appears  to  be  generally  accepted  that  injuries  are  to  be  compensated 
irrespective  of  pre-existing  tendencies  or  the  subnormal  condition  of 
the  injured  workman,  provided  that  the  immediate  injury,  whether 
accelerating  or  exaggerating  the  pre-existing  condition,  proximately 
arises  from  the  employment. 

"  Causes  of  Accident. — It  is  not  necessary  that  the  injury  should 
arise  from  an  extraneous  cause.  It  may  be  caused  by  nervous  shock 
without  external  physical  change.  It  may  result  from  the  wilful  or 
even  criminal  act  of  another,  as  where  a  watchman  is  wounded  while  de- 
fending his  employer's  property,  or  a  foreman  is  assaulted  because  of  the 
administration  of  a  reprimand  for  doing  work  improperly,  or  a  mill 
superintendent  murdered  by  an  ejected  person. 

"Further  Broadening  of  the  Liability  of  the  British  Act. — The 
restrictions  diminished  by  the  ehmination  of  the  word  'accident' 
from  the  definition  of  hability  are  yet  further  lessened  by  striking  out 
the  phrase  'out  of  and  permitting  hability  to  remain  merely  for  in- 


676  INDUSTRIAL    MEDICINE    AND    SURGERY 

juries  received  'in  the  course  of  employment.'  'Many  accidents  occur 
in  the  course  of,  but  not  out  of,  the  employment;  but  I  am  unable  to 
think  of  any  that  could  arise  out  of,  and  not  also  in  the  course  of  the 
employment.'  These  words  by  Justice  Farwell  express  the  effect 
of  the  elimination  of  'out  of  in  many  state  acts,  for  it  is  obvious 
that  an  injury  may  be  received  in  the  course  of  employment  while 
the  cause  is  unrelated  to  such  employment. 

"Elimination  of  'Out  of.' — The  phrase  'out  of '  has  been  generally 
held  to  fix  the  cause  or  source  of  the  accident  or  injury,  while  the 
term  'in  the  course  of  definsd  the  time,  place,  and  circumstance  of 
its  occurrence.  Numerous  decisions  of  the  courts  respecting  statutes 
carrying  this  conjunctive  phrase  emphasize  the  fact  that  mere  injury 
while  performing  a  duty  of  service  gives  no  claim  for  compensation 
unless  an  essential  relation  is  established  between  the  employment  and 
the  injury.  This  requirement,  of  course,  fails  when  it  is  merely  nec- 
essary to  show  that  the  injury  arises  during  'the  course'  of  the  em- 
ployment. It  may  thus  be  caused  through  the  violence  of  a  fellow- 
workman  or  a  stranger,  but  not  by  'horseplay.'  The  Ohio  Industrial 
Commission  awarded  compensation  to  the  dependents  of  a  stenog- 
rapher because  of  her  murder  by  a  jealous  suitor  while  taking  the 
dictation  of  her  emplbyer. 

"Special  Liability  Suggested  by  Connecticut  Commission. — 'In- 
juries during  the  course  of  employment'  are  beginning  to  include, 
and  have  already  by  precedent  included,  forms  of  infection  or  conta- 
gion which  are  incidental  rather  than  inherent  in  employment.  This 
tendency,  necessarily  reflected  in  an  increasing  severity  of  physical 
examination  in  the  jurisdiction  in  which  it  is  most  evident,  doubtless 
inspired  the  suggestion  of  the  Connecticut  Commission  in  1915,  that 
persons  suffering  from  inherent  physical  defects,  making  them  a 
peculiar  hazard,  shall  be  permitted  to  make  special  stipulations  with 
regard  to  compensation,  subject  to  the  approval  of  the  com- 
mission, as  a  practical  means  of  preventing  their  exclusion  from 
employment. 

"Proximate  Causes  of  Injury. — In  substantially  all  state  juris- 
dictions the  burden  of  proof  rests  on  the  claimant  to  show  that  the 
accident  or  injury  recited  is  the  proximate  cause  of  the  alleged  dis- 
ability or  death,  but  'proximate  cause  under  the  law  of  negligence 
always  has  to  be  traced  back  to  the  conduct  of  responsible  human 
agencies;  under  the  compensation  act  the  words  "proximate  cause  by 
accident"  in  terms  relate  to  a  physical  fact  only,  namely,  an  accident. 
Hence  if  the  injury  or  death  can  be  traced  to  physical  cause  not 
too  remote  in  time  or  place  to  the  accident,  then  such  injury  or 
death  was  proximately  caused  by  the  accident,  irrespective  of  any 
element  of  reasonable  anticipation.     The  term  ''  proximate  "  was,  no 


employees'  compensation  677 

doubt,  used  to  exclude  physical  causes  so  remote  in  time  and  place, 
or  both,  as  to  make  them  of  doubtful  value  in  tracing  the  relation 
between  cause  and  effect.' 

"Pre-existing  Disease  or  Injury. — The  view  of  the  Wisconsin 
Supreme  Court  seems  an  excellent  statement  of  the  substantial  prin- 
ciple. It  applies  equally  to  all  forms  of  disease  of  physical  consequence 
where  there  is  a  causal  connection  between  them  and  the  injury. 
Inasmuch  as  the  employer  is  said  to  take  workmen  as  he  finds  them, 
he  becomes  responsible  for  disabilities  which  are  the  direct  result  of 
an  injury  or  accident  aggravating  a  previous  physical  condition. 
Thus  compensation  is  allowed  for  death  caused  through  an  infected 
heel  blister  poisoning  the  blood  stream  and  causing  Bright's  disease,  or 
death  from  pneumonia  where  the  power  of  resistance  has  been  reduced 
by  an  occupational  strain,  or  death  following  an  inflammation  of  a 
pre-existing  cancer  due  to  an  accidental  blow,  or  where  a  weak  heart 
is  impaired  by  the  muscular  exertion  of  the  work.  Where  the  causal 
connection  is  complete  the  principle  applies,  although  merely  ac- 
celerating pre-existing  disease,  or  where  the  injury  ultimates  in 
insanity  or  suicide.  If,  however,  a  second  independent  cause  inter- 
venes at  any  point  the  causal  chain  is,  of  course,  broken  and  the 
liability  ceases.     The  question  is  always  one  of  fact. 

"Aggravation  of  Injury. — The  aggravation  of  the  injury  or  dis- 
ability by  the  conduct  of  the  workman  carelessly,  negligently,  or  un- 
reasonably preventing  cure  or  making  the  condition  worse  is  ground 
for  stopping  compensation.  The  too  early  use  of  a  broken  limb, 
resulting  in  a  second  injury  to  it,  will  not  permit  a  second  compensa- 
tion. A  second  disability  produced  by  awkwardness  or  clumsiness 
as  a  natural  result  of  the  first  is,  however,  further  compensable. 
The  prolongation  of  working  incapacity  due  to  the  use  of  intoxicating 
liquors  is  not  compensable.  The  Supreme  Courts  of  Wisconsin 
and  Washington  have  held  the  employer  liable  for  death  or  disability 
resulting  from  the  professional  incompetence  of  the  physician  sup- 
pHed  by  him.  Death  resulting  from  an  operation  necessitated  by  the 
original  injury  is  compensable. 

"Refusal  of  Medical  Instruction  or  Recommendation. — As  a  rule, 
prolonged  disability  due  to  disobedience  of  the  physician's  instructions 
is  not  compensable.  The  question  of  whether  or  not  a  workman 
is  unreasonable  in  refusing  to  submit  to  an  operation  advised  by  a 
physician  to  cure  disability  or  save  hfe  must  rest  upon  the  circum- 
stances of  the  case.  Thus  it  has  been  held  by  a  high  English  author- 
ity that  it  is  not  unreasonable  to  refuse  to  submit  to  an  operation  in- 
volving risk  of  life.  On  the  other  hand,  it  has  been  held  unreasonable 
to  refuse  to  submit  to  a  minor  operation  to  restore  the  use  of  a  finger  or 
a  hand  in  a  skilled  trade. 


678  INDUSTRIAL   MEDICINE    AND    SURGERY 

"Hernia. — Hernia  is  a  special  subject  of  decision  and  administrative 
rule.  As  a  result  of  many  difficult  claims  and  considerable  fraud  the 
authoritative  rule  seems  to  be  that  there  will  be  a  strong  presumption 
against  a  hernia  directly  arising  from  an  accidental  injury  which  will 
not  be  overcome  by  merely  showing  that  hernia  is  coincidental  with 
some  exceptional  exertion.  Decisions  respecting  hernia  are  by  no 
means  harmonious.  The  Oregon  Commission  requires  hernia  claim- 
ants to  provide  affidavits  establishing  the  non-existence  of  hernia  be- 
fore the  accident.  The  Washington  Commission  requires  proof  that 
hernia  is  of  recent  origin,  is  accompanied  by  pain,  was  immediately 
preceded  by  an  accidental  strain  and  did  not  previously  exist.  The 
Nevada  Commission  has  Hkewise  adopted  strict  definite  rules. 

"Disfigurement. — Injuries  causing  mutilation  or  disfigurement 
accompanied  by  disabihty  to  pursue  the  previous  or  other  occupation 
have  received  considerable  legislative  and  judicial  attention.  Nine 
states  have  made  statutory  provisions  confined  as  a  rule,  however, 
to  compensation  for  mutilation  of  the  head  or  features.  The  acts  of 
Vermont  and  Kentucky  require  that  for  the  purpose  of  compensation 
mutilation  must  cause  lessened  capacity  to  secure  employment.  The 
Iowa  Commission  in  the  absence  of  a  statutory  provision  held  it 
would  allow  compensation  only  if  it  could  be  shown  that  the  work- 
ing capacity  was  affected.  The  New  York  courts  share  this  view, 
that  of  Illinois  modifies  it. 

"Occupational  Disease  as  an  Accident. — In  Great  Britain  certain 
forms  of  occupational  disease  resulting  from  infection,  like  anthrax, 
were  held  to  be  a  'personal  injury  by  accident.'  By  later  legislation 
all  occupational  disease  is  defined  in  a  separate  statute  to  which  ad- 
ditions are  made  by  order  of  the  Secretary  of  State.  In  our  own 
legislation  there  is  now  a  marked  tendency  to  require  separate  pro- 
vision for  such  disease  and  to  deny  it  compensation  as  an  '  accident. ' 
The  Supreme  Courts  of  Connecticut,  Michigan,  and  Ohio,  have  held 
their  respective  acts  do  not  include  occupational  disease,  although 
the  term  'injury'  and  not  'accident'  quahfies  the  statute  of  each  of 
these  states.  The  Supreme  Court  of  Massachusetts,  on  the  contrary, 
has  held  that  the  term  'personal  injury'  includes  occupational  disease. 
The  construction  and  practice  of  administrative  commissions  indicates 
an  increasing  tendency  to  allow  compensation  for  many  forms  of 
disease  contracted  during  employment  without  requiring  a  clear 
proximate  relation  thereto  to  be  established." 

The  htigation  of  claims  in  the  past  (still  existant  in  several  states), 
involving  as  it  did,  the  employment  of  lawyers  by  both  sides,  the 
hiring  of  expert  medical  witnesses  and  the  expense  to  the  state  of 
providing  judge  and  jury  was  one  of  the  most  wasteful  practices  in 
the  industrial  world.     The  poor  employee,  who  is  entitled  to  some 


employees'  compensation  679 

compensation  for  his  injuries  and  who  found  it  neceseary  to  fight 
his  case  through  a  bewildering  maze  of  technicaUties,  usually  came 
out  at  the  little  end  of  the  horn  after  paying  his  lawyer  and  his  witnesses 
tteir  portion  of  the  settlement.  As  a  general  rule  the  various  com- 
pensation acts  have  eliminated  this  wasteful  practice  to  a  large  extent 
but  in  many  cases  the  injured  employee  still  consults  his  lawyer 
and  the  latter  pleads  his  case  before  the  Compensation  Commissions. 
It  is  fortunate  that  in  some  states  the  findings  of  the  Industrial  Com- 
mission can  be  refuted  by  the  courts  and  even  a  jury  may  make  the 
final  decision  in  the  case.  It  would  seem  desirable  to  eliminate  both 
lawyers  and  expert  witnesses  as  far  as  possible  before  the  Industrial 
Commissions,  reserving  this  for  the  few  cases  which  must  be  referred 
to  the  courts. 

The  members  of  the  Industrial  Commission  are  not  lawyers  as  a 
rule  and  they  are  often  easily  bewildered  by  the  legal  phraseology 
or  technicalities  injected  into  their  hearings  by  the  legal  profession. 
The  employer  can  often  afford  to  engage  the  services  of  a  good  lawyer 
and  the  employee,  therefore,  feels  compelled  to  have  a  legal  representa- 
tive, often  of  an  inferior  grade.  If  a  medical  expert  is  secured  by  the 
one,  the  other  feels  compelled  to  procure  his  expert.  As  a  result  a 
full-fledged  trial  with  its  accompanying  expense  to  both  sides  is 
conducted  before  a  lay  board. 

In  order  to  completely  obviate  this  needless  expense  and  to  assure  the 
full  amount  of  the  settlement  to  the  employee  without  deducting  fees 
for  legal  and  medical  experts,  these  commissions  should  act  purely 
as  referees  between  the  claimant  and  defendant  and  when  either  legal 
or  medical  professional  advice  is  needed  they  should  obtain  it  from 
disinterested  representative  members  of  these  professions.  An 
equitable  settlement  could  thus  be  arrived  at  in  the  majority  of  cases; 
only  a  small  minority  would  need  to  be  referred  to  the  courts. 

The  employment  of  medical  staffs  by  many  industrial  commis- 
sions is  now  taking  place.  This  practice  will  undoubtedly  extend  to 
all  the  commissions  in  the  course  of  time.  More  than  half  the  claims 
appearing  before  Industrial  Boards  involve  the  question  of  the  extent 
of  the  disability.  When  the  plant  physician  claims  that  the  disability 
is  temporary  or  that  only  25  per  cent,  of  the  function  is  lost  in  an 
injured  member  and  the  employee  or  his  physician  claim  that  the  disa- 
bility is  permanent  or  at  least  50  per  cent,  of  the  function  is  lost,  one  of 
the  expert  medical  men  on  the  staff  of  the  Commission  can  examine 
the  case  and  often  arrive  at  a  definite  solution  of  the  question  of  disa- 
biUty.  When  necessary,  these  medical  men  are  empowered  to  employ 
consultants  who  likewise  are  disinterested  parties.  The  testimony, 
therefore,  of  these  consultants  and  their  own  doctor  form  the  basis 
of  settlement  for  the  Commission. 


680  INDUSTRIAL   MEDICINE    AND    SURGERY 

In  order  for  such  a  plan  to  successfully  operate  the  Industrial 
Boards  are  realizing  more  and  more  the  importance  of  employing  the 
very  best  surgical  talent  of  the  community  on  their  medical  staffs. 
As  stated  by  Mr.  Andrus,  these  medical  men  on  the  Commission  can 
influence  employers  to  use  only  the  best  surgeons  in  their  accident 
work.  If  a  surgeon  is  constantly  obtaining  poor  functional  results 
in  his  cases  and  then  appears  before  the,  Industrial  Commission  en- 
deavoring to  camouflage  his  mistakes  by  belitthng  the  employees' 
disability,  both  the  Commissioners  and  their  doctors  soon  recognize 
the  facts  and  are  in  a  position  to  point  out  to  the  employer  the  reasons 
for  the  high  compensation  claims  he  is  forced  to  pay. 

Another  advance  in  the  administration  of  these  compensation  acts 
is  seen  in  the  increased  interest  which  the  various    industrial   com- 


FiG.  195. — This  patient  who  lost  parts  of  both  hands  and  sustained  total  functional 
disability  from  electrical  burns  has  been  fitted  with  artificial  appliances  and  is  receiving 
practical  vocational  training  for  a  better  job  in  the  industry  where  he  was  injured. 
He  was  awarded  total  disability  benefit.  Compensation  alone,  however,  would  not 
assure  his  future. 

missions  are  taking  in  the  re-employment  or  the  rehabihtation  of  these 
injured  employees.  In  this  connection  they  are  demanding  better 
functional  results  from  the  surgical  treatment  given  and  they  are  insist- 
ing upon  the  re-employment  of  disabled  men  in  occupations  where  their 
remaining  functions  can  be  used  to  the  utmost.  The  Cahfornia  Com- 
mission ''feels  that  the  Workmen's  Compensation,  Insurance  and 
Safety  Act  places  an  obhgation  on  it  which  is  not  specifically  defined  in 
the  text  of  the  law. "  That  is,  it  feels  responsible  for  the  surgical  results 
to  the  injured  working  men  coming  under  its  care.  It  feels  that  be- 
sides scrutinizing  results  from  the  standpoint  of  indemnities  deserved, 


employees'  compensation  681 

it  should  scrutinize  them  from  the  standpoint  of  good  surgery  and  sur- 
gery which  might  have  been  accorded.  Again  we  find  this  broader 
interpretation  of  the  duties  imposed  upon  the  Industrial  Commis- 
sion in  the  following  remarks  made  by  the  Chairman  of  the  IlUnois 
Industrial  Commission:  ''It  frequently  happens  that  a  laboring  man 
has  an  arm  amputated  and  honestly  considers  that  there  is  nothing 
further  that  he  can  do  and  that  his  usefulness  is  forever  gone.  The 
state  has  not  done  its  duty  to  this  man  by  merely  paying  him  his  com- 
pensation, which  is  soon  gone.  He  should  be  trained  for  other  work. 
The  treatment  is  mental  as  well  as  physical  and  should  be  a  part  of 
the  work  of  the  medical  department.  Such  a  man  should  be  definitely 
trained  for  some  other  line  of  work  in  which  he  may  be  made  a  100 
per  cent.  man.  I  lay  emphasis  upon  this  100  per  cent,  man  as  that  is 
the  aim  of  the  rehabilitation." 

From  the  above  resum^  of  the  various  compensation  acts  and  the 
tendency  of  the  different  commissions  responsible  for  their  adminis- 
tration to  extend  their  duties  along  humanitarian  lines  it  is  evident 
that  the  surgeon  in  industry  must  have  a  close  relationship  to  these 
commissions.  The  surgeon  must  realize  that  dependent  upon  the 
results  of  his  work  many  things  are  at  stake.  For  instance,  to  a  large 
extent  he  can  control  the  amount  of  temporary  or  permanent  disa- 
bility which  the  injured  employee  must  sustain;  he  can  influence  the 
amount  of  compensation  which  the  employer  must  pay;  he  can  directly 
increase  or  decrease  the  expenses  of  the  state  government  by  the  char- 
acter of  his  service.  The  character  of  his  work  is  not  gauged  by  the 
surgical  results  only  but  must  deal  likewise  with  the  mental  attitude 
of  the  patient.  By  kindness,  tact  and  justice  the  surgeon  can  settle 
many  a  claim,  which  would  otherwise  come  before  the  industrial  com- 
mission. Thus  many  a  surgeon  in  industry  has  entered  a  field  of 
socialized  medicine  without  knowing  it.  Industrial  commissions  are 
recognizing  the  doctor's  value  in  this  work.  "The  character  of  the 
medical  service  rendered  to  the  individuals  who  have  been  injured 
determines  to  a  larger  extent  than  would  appear  on  the  surface,  the 
length  of  disability.  The  question  is  not  only  one  of  recovery  from 
the  injury  with  the  least  possible  deformity;  it  goes  further  than  this. 
It  involves  the  restoration  to  full  function  which  often  depends  upon 
complex  psychic  conditions.  The  function  of  the  surgeon  is  more 
than  mechanical.  He  must  be  the  physician  and  he  must  be  in  sym- 
pathy with  his  patient.  He  must  treat  him  as  his  mental  endowment 
and  as  his  mental  attitude  require,"  (Industrial  Accident  Com- 
mission of  California.) 

Further  proof  of  the  doctor's  importance  in  this  field  is  seen  in  the 
following  words  from  the  same  Commission:  "The  more  personal  the 
touch  between  the  doctor  and  his  patient  the  more  confidence  will  be 


682  INDUSTRIAL    MEDICINE    AND    SURGERY 

established  and  the  better  and  quicker  will  be  the  result.  The  same 
theory  applies  equally  well  to  the  relation  between  the  State  Compen- 
sation Fund  and  the  doctors." 

The  very  fact  that  more  claims  for  settlements  come  from  those 
groups  of  employees  dependent  upon  insurance  companies  for  their 
settlements  and  their  medical  service  is  due  to  the  lack  of  this  personal 
interest  of  the  doctor  in  his  patient.  Too  many  insurance  companies 
employ  cheap  medical  service  and  have  an  insufficient  number  of 
doctors  to  adequately  care  for  the  employees  under  them.  These 
conditions  plus  the  endeavor  of  the  company  to  secure  the  cheapest 
possible  settlement  causes  dissatisfaction  among  the  injured  and 
leads  to  injustice  and  misunderstanding  for  both  parties.  The  injured 
employee,  worried  by  bickering,  is  more  liable  to  develop  neuroses, 
especially  neurasthenia.  Thus,  added  to  the  increased  number  of  cases 
requiring  settlement  are  those  cases  which  develop  prolonged  disa- 
bihty.  Both  of  these  groups  could  be  reduced  by  better  medical  care 
and  by  establishing  the  personal  contact  between  the  employer,  the 
doctor  and  the  patient. 

There  are  several  things  which  the  surgeon  in  industry  must  do 
which  have  a  direct  bearing  upon  his  relationship  to  compensation: 

1.  He  must  consider  every  case  as  serious  from  its  inception.  Even 
the  minor  cases  must  be  recognized  as  potential  major  conditions. 
Only  in  this  way  can  a  careless,  temporizing  method  of  treatment  be 
avoided.     This  implies  immediate  emergency  treatment  for  all  injuries. 

2.  The  surgeon  responsible  for  the  complete  care  of  the  case  should 
take  charge  as  soon  as  possible,  preferably  he  should  render  the 
emergency  treatment.  He  should  carefully  supervise  all  the  details 
connected  with  the  care  of  the  patient  and  should  not  leave  important 
dressings  or  other  vital  matters  connected  with  the  treatment  to  the 
internes  or  assistants.  In  no  other  way  can  he  keep  the  patient 
absolutely  satisfied,  a  most  essential  factor  in  all  personal  injury  cases. 

3.  Rough  handling  of  injured  employees,  gruff ness,  an  unsympa- 
thetic manner  of  approach,  or  treating  them  as  though  they  were 
"charity  cases"  will  not  reduce  the  number  of  compensable  cases. 
Gentleness,  cheerfulness  and  a  sympathetic  attitude  are  the  essential 
attributes  of  the  good  accident  surgeon.  Dissatisfaction  among  the 
injured  increases  the  amount  of  compensation.  It  leads  to  various 
types  of  neuroses;  it  delays  recovery;  and  it  robs  the  surgeon  of  the 
opportunity  of  hastening  the  return  to  work.  The  patient  may  com- 
plain of  the  hospital  food  or  of  mistreatment  on  the  part  of  the  nurse 
or  interne,  or  other  imaginary  or  real  abuses.  The  surgeon  should 
promptly  note  these  signs  of  discontent,  diplomatically  learn  the  details 
from  the  patient  and  run  down  every  complaint  to  its  source  with  the 
view  to  correcting  the  same.     A  lack  of  interest  in  the  patient's 


EMPLOYEES     COMPENSATION 


683 


comfort  is  a  frequent  fault  with  surgeons.  The  patient  may  object 
to  being  placed  in  a  ward  and  may  demand  a  private  room  in  the 
hospital.  Usually  the  surgeon  can  remove  such  objections  by  a  little 
patient  diplomacy  but  occasionally  he  will  find  that  he  can  decrease 
the  compensation  by  yielding  to  the  patient's  or  the  family's  desire. 
Often  a  private  room  and  other  luxuries  which  may  have  to  be  in- 
cluded in  the  treatment  are  cheaper  than  a  dissatisfied  patient. 


Fig.  196. — An  armless  soldier  learning  to  use  his  artificial  appliance  and  at  the  same 
time  receiving  instruction  in  a  new  trade,  acetylene  welding. 

4.  The  best  emergency  treatment,  constant  watchfulness  for 
compHcations  and  continuous  active  treatment  until  cure  is  ac- 
comphshed  will  give  the  desired  surgical  end-result.  But,  in  the 
words  of  one  of  our  Army  Medical  Officers,  "surgeons  must  free  them- 
selves from  their  tendency  to  treat  the  wounds  and  forget  the  function; 
to  make  a  well  man  but  not  a  working  one;  to  take  the  anatomic 


684  .  INDUSTRIAL    MEDICINE    AND    SURGERY 

rather  than  the  physiologic  point  of  view."  In  accident  surgery  the 
physiologic  is  the  economical  point  of  view.  In  order  to  attain  this 
functional  result  the  injured  must  be  encouraged  to  early  use  the 
injured  member  in  spite  of  the  temporary  pain  and  discomfort  such 
use  may  occasion.  It  is  often  desirable  to  remove  the  patient  from 
the  environment  of  the  hospital  as  soon  as  possible  even  though  it 
may  inconvenience  the  surgeon  to  a  certain  extent.  Again  recovery 
maybe  hastened  and  a  workable  functional  result  obtained  more  quickly 
by  getting  the  injured  party  back  in  the  industry  on  some  light  work 
even  though  it  is  for  part  of  the  day  only.  The  injured  party  may 
refuse  to  consent  to  this  therapeutic  use  of  light  work  on  the  grounds 
that  to  return  to  work  means  the  loss  of  further  compensation.  The 
surgeon  must  persuade  the  management  to  pay  such  employees  their 
full  wages  from  the  time  they  return  to  this  light  occupation, 
even  though  the  man  is  not  earning  them;  pointing  out  that  in  this 
way  his  recovery  is  hastened  and  compensation  for  permanent  disa- 
bility often  avoided. 

5.  Honesty  and  justice  must  be  the  controlling  motives  of  the  sur- 
geon in  deciding  the  points  relative  to  compensation.  He  cannot 
afford  to  take  the  side  of  the  employer  as  opposed  to  the  employee  nor 
vice  versa.  However,  both  the  employer  and  the  surgeon  will  find 
that  a  generous  policy  toward  injured  employees  is  more  economical 
in  the  long  run.  In  the  concern  with  which  the  author  was  connected 
the  slogan  of  the  management  was  "Give  the  employees  the  benefit 
of  the  doubt."  Industry  in  the  past  has  had  many  company  doctors 
but  these  are  gradually  being  replaced  by  the  employees'  doctors. 
Any  surgeon  who  regards  the  interest  of  the  employees  will  best 
be  serving  the  interests  of  the  company.  This  is  the  attitude,  there- 
fore, which  should  be  adopted  in  claims  for  compensation. 

6.  When  the  surgeon  is  called  before  the  industrial  commission 
or  before  the  court  to  testify  in  cases  claiming  settlements  he  must  be 
guided  by  this  same  policy  of  honesty  and  justice.  All  the  information 
which  he  can  give  which  will  assist  the  court  in  arriving  at  an  equitable 
adjustment  of  the  case  should  be  given.  The  withholding  of  valual5le 
information  in  order  to  protect  the  industry  employing  the  surgeon  is  a 
short  sighted  policy.  It  is  a  mistaken  type  of  loyalty  and  no  doctor 
can  expect  to  retain  the  respect  of  the  management  or  the  confidence 
of  the  employees  by  adopting  such  a  method. 

7.  Frequently  the  family  physicians  are  responsible  for  many  of 
the  claims  for  compensation.  A  snap-shot  diagnosis  of  a  broken  bone, 
a  dislocated  vertebra,  a  displaced  uterus,  internal  injuries  and  like 
conditions,  when  they  do  not  exist  will  give  the  injured  party  an 
exalted  idea  as  to  the  extent  of  his  injury  and  cause  him  to  make  exces- 
sive claims  for  damages.     Realizing  this  human  trait,   all  doctors 


employees'  compensation  G85 

should  be  very  conscientious  in  making  their  diagnoses  and  very 
guarded  in  tlfe  statements  which  they  make  to  the  injured  person. 
Many  of  the  traumatic  neuroses,  with  their  prevaihng  disabihty  and 
their  needless  compensation  result  purely  from  these  false  notions 
gained  from  the  exaggerated  statements  of  doctors. 

Many  surgeons  with  wide  experience  in  handling  these  accident 
cases  feel  very  strongly  that  some  of  the  principles  of  the  compensation 
acts  are  wrong.  For  instance,  the  waiting  period  will  often  cause  an 
employee  to  prolong  his  disability  in  order  to  receive  compensation. 
The  provision  that  a  pre-existing  disability  will  add  to  the  em- 
ployer's responsibility  in  case  of  subsequent  accident  is  wrong  because 
it  tends  to  make  employers  discriminate  against  those  applicants  for 
work,  and  even  the  old  employees,  who  are  unfortunate  enough  to 
possess  some  handicap.  To-day  many  employers  refuse  to  hire  a 
man  blind  in  one  eye  because  they  will  be  held  responsible  for  total 
blindness  in  case  of  loss  of  the  other  eye.  The  amount  of  weekly 
compensation  provided  by  the  majority  of  the  laws  for  the  injured 
party  is  inadequate.  Many  employees  are  injured,  not  through 
their  own  carelessness,  but  because  the  industry  has  failed  to  provide 
the  proper  preventive  measures.  Nevertheless,  this  employee  is 
forced  to  lose  his  total  wage  for  at  least  one  week  and  then  to  receive 
only  a  portion  of  his  wages  over  a  period  lasting  several  weeks.  He 
may  have  a  large  family  and  his  earnings  have  hardly  been  sufficient 
to  provide  the  necessities  of  life.  After  he  is  injured,  hardships  and 
distress  are  placed  upon  the  family  because  of  the  reduced  amount  of 
money  paid  to  him.  The  worry  and  dissatisfaction  engendered  in  the 
patient's  mind  because  of  these  conditions  prolong  his  disabihty. 
Surgeons  in  industry  are  witnessing  this  almost  every  day  and  the 
various  legislatures  should  certainly  provide  some  more  equitable 
arrangement. 

With  the  return  of  the  disabled  soldiers  from  the  present  war 
the  problems  confronting  the  plant  surgeon  will  be  greatly  increased. 
After  the  sense  of  gratitude  and  the  present  patriotic  fervor  have 
quieted  down,  many  employers  may  refuse  to  hire  these  disabled  men 
because  of  the  possible  increased  insurance  rate  or  the  increased 
amount  of  compensation  which  may  result.  At  present,  there  is  a 
strong  feeling  that  present  compensation  acts  must  be  amended  so 
that  employers  will  not  be  held  responsible  for  the  pre-existing  dis- 
abilities. A  Federal  law  may  be  necessary,  establishing  a  fund  for 
the  purpose  of  compensating  that  portion  of  the  disability  which  is 
traceable  to  the  employee's  service  in  the  army.  That  some  arrange- 
ment is  necessary  to  meet  this  problem  is  agreed  by  all  cognizant  with 
the  situation. 

The  surgeon,  therefore,  dealing  with  these  returned  soldiers  will 


686  INDUSTRIAL   MEDICINE    AND    SURGERY 

often  be  confronted  with  the  problem  of  whether  the  man's  disabiHty 
is  due  entirely  to  some  condition  connected  with  his  work,  whether 
his  disability  following  an  accident  is  made  worse  because  of  some 
pre-existing  war  condition  or  whether  the  disability  is  only  the  recur- 
rence of  some  condition  the  result  of  his  army  service.  Much  of  the 
supervision  of  the  health  and  subsequent  physical  condition  of  these 
returned  soldiers  will  devolve  upon  the  surgeon  in  industry  and  he 
must  be  awake  to  the  situation.  In  this  connection  it  is  of  consider- 
able interest  to  know  how  the  European  countries  are  meeting  these 
problems  relative  to  workmen's  compensation  in  relation  to  the 
soldier. 

In  Germany  the  director  of  the  Imperial  Insurance  Office  in 
February,  1915,  said, ''  cripples  who  enter  industry  after  discharge  from 
the  army  will  increase  the  dangers  coincident  to  a  trade.  Owing  to 
their  slower  movements  they  are  more  liable  to  danger.  They  also 
increase  the  danger  to  their  healthy  fellow  workers.  The  number  of  ac- 
cidents and  the  burden  of  compensation,  will,  therefore,  be  immensely 
increased."  The  remedy  proposed  in  Germany  is  not  a  change  in 
the  insurance  law  but  rather  a  development  of  the  therapeutic  facilities 
already  in  operation  by  the  accident  insurance  associations.  The 
hospitals  of  these  associations  have  specialized  in  the  rehabilitation 
and  training  of  cripples.  It  was  decided  to  give  5  per  cent,  of  the  fund, 
of  each  State  Insurance  pffice  for  the  erection  of  hospitals  where  these 
crippled  soldiers  could  be  rehabilitated  and  trained  for  special  employ- 
ment. By  this  method  it  was  beheved  that  these  cripples  could  be 
made  as  good  a  risk  as  a  sound  man.  After  his  employment,  if  a  dis- 
abled soldier  receives  an  accident  he  is  entitled  to  compensation  under 
the  insurance  law  even  though  he  is  receiving  a  mihtary  allowance  for 
the  pre-existing  disability.  The  matter  of  re-employing  former 
workmen  who  have  been  crippled  in  the  war  has  been  made  a  patriotic 
issue  in  Germany.  Although  employment  means  insurance,  employers 
have  shown  great  readiness  to  accept  the  responsibihty.  The  Fred- 
erick Krupp  Corporation,  not  only  provides  employment  for  such  men 
but  gives  them  vocational  training  in  a  special  workshop  to  fit  them  for 
a  place  where  they  can  safely  work. 

In  France  this  problem  of  the  returned  disabled  soldier  in  industry 
has  already  been  met  by  an  act  known  as  the  Law  of  November  25, 
1916. 

"This  law  provides,  that  when  a  person  suffering  a  disability 
received  in  the  present  war  meets  with  an  industrial  accident,  the 
court  which  fixes  the  amount  of  compensation  due  him  shall  state, 
first,  whether  the  accident  was  caused  by  his  previous  disability,  and, 
second,  to  what  extent  the  permanent  reduction  of  his  earning  ca- 
pacity following  the  accident  was  due  to  his  disabihty.     If  the  court 


employees'  compensation  687 

finds  that  the  accident  was  caused  exclusively  by  the  pre-existing  dis- 
abihty  (received  in  the  war),  the  employer  shall  be  absolved  from  all 
obHgations  to  pay  any  part  of  the  allotted  compensation;  and  if  the 
court  finds  that  the  reduction  of  the  workmen's  earning  capacity 
after  an  accident  was  due  in  part  to  his  previous  disability,  the  em- 
ployer shall  not  be  required  to  pay  the  whole  compensation,  but  only 
that  part  which  corresponds  to  the  actual  consequences  of  the  accident. 
The  compensation  from  which  the  employer  is  thus  absolved  shall  be 
paid  to  the  workman  by  the  state  through  the  Caisse  national  des 
restraites  pour  la  viellesse,  which  shall  receive  the  money  from  a  special 
benefit  fund^  created  for  that  purpose.  The  special  benefit  fund  shall 
be  supported  by  a  tax  on  employers  and  insurance  companies.  A 
translation  of  the  text  of  the  law  follows: 

*'  'A  Law  concerning  Persons  Disabled  in  the  War,  who  later  become 
the  victims  of  Industrial  Accidents.  Passed  by  the  Senate  and 
Chamber  of  Deputies,  and  promulgated  by  the  President  of  the 
Republic. 

"  'Article  I.  Whenever  a  soldier,  a  sailor,  or  non-combatant  attached 
to  the  army,  suffering  serious  and  incurable  disabihties  as  a  result 
either  of  wounds  received  in  the  course  of  war  or  while  in  government 
service  during  the  present  war,  or  as  a  result  of  sickness  contracted 
or  aggravated  by  the  fatigues  or  dangers  of  service  during  the  present 
war,  shall  be  a  victim  of  an  industrial  accident  under  conditions  pro- 
vided for  by  the  laws  of  April  9,  1898,  June  30,  1899,  April  12,  1906, 
July  18,  1907  and  July  15,  1914,  the  decree  of  the  president  of  the  court 
or  the  judgment  of  the  court  which  fixes  the  amount  of  compensation 
for  his  death  or  for  the  permanent  reduction  of  his  capacity  for  work 
must  expressly  state  its  findings  with  reference  to  the  following 
points : 

*"  1 .  Whether  the  accident  was  caused  exclusively  by  the  pre-existing 
disability  resulting  from  the  war. 

"  '2.  Whether  the  permanent  reduction  of  capacity  resulting  from 
the  accident  was  increased  by  said  disability,  and  to  what  extent. 

"'In  reference  to  Point  1,  an  affirmative  decision  of  the  court  shall 
absolve  the  industrial  concern  from  all  obfigation  to  pay  any  part  of 
the  compensation  allotted  to  the  victim  by  the  decree  or  judgment; 
in  reference  to  Point  2,  when  the  court  has  decided  to  what  extent 
the  permanent  reduction  of  the  worker's  capacity  resulting  from  the 
accident  was  increased  by  the  pre-existing  disabiHty. 

"  'The  compensation  from  which  the  employer  is  thus  absolved  shall 
be  paid  by  the  National  Pension  Fund  for  Aged  People,  ^  which  shall 
receive  the  money  from  a  special  Benefit  Fund  for  men  wounded  in 

^  Fonds  special  de  prevoyance  des  blesses  de  la  guerre. 
2  Caisse  national  des  retraites  pour  la  vieillesse. 


688  JNDUSTKUAL    MEDICINE    AND    SURGERY 

the  war.^  The  activities  of  the  special  benefit  fund  shall  be  directed 
by  the  ministry  of  labor,  ^  and  its  finances  by  the  Fund  of  Deposits 
and  Consignments.^ 

"  'The  special  Benefit  Fund  shall  be  supported  by  assessments  on 
employers  and  insurance  companies,  the  rate  of  which  assessments 
shall  be  fixed  each  year  by  the  finance  law^  according  to  the  cir- 
cumstances indicated  in  article  25  of  the  law  of  April  9,  1898,  in  articles 
4  and  5  of  the  law  of  April  12,  1906,  modified  by  the  law  of  March 
26,  1908,  in  article  4  of  the  law  of  July  18,  1914,  concerning  the  different 
classes  of  employers;  and  in  article  27,  last  paragraph,  of  the  law  of 
April  9,  1898,  modified  by  that  of  March  31,  1905,  concerning  in- 
surance companies. 

"  'Article  II.  A  decree  issued  after  consultation  with  the  Advisory 
Committee  of  the  Industrial  Accident  Insurance  Companies  shall 
determine  the  organization  and  activities  of  the  special  Benefit  Fund 
mentioned  in  the  preceding  article.  The  counsel  for  the  controller 
of  private  insurance  companies  shall  be  a  member  of  said  Advisory 
Committee  by  virtue  of  his  office. 

'"Article  III.  Temporarily,  for  the  years  1916,  1917  and  1918,  the 
assessments  collected  from  industrial  concerns  and  insurance  com- 
panies in  the  application  of  the  preceding  provisions  of  the  law  shall 
be  equal  to  a  third  of  the  assessments  provided  by  the  following  laws: 

*"l.  The  decree  of  May  28,  1915,  concerning  factory  licenses  and 
operators; 

"  '2.  The  law  of  December  13,  1912,  concerning  the  application  of 
paragraphs  2  and  3  of  article  5  of  the  law  of  April  12,  1906; 

"  '3.  The  decree  of  the  ministry  of  labor  fixing  the  cost  of  regula- 
tion and  supervision  of  insurance  companies  for  the  year  1913. 

"  'Article  IV.  After  the  accounts  of  the  special  Benefit  Fund  for  men 
wounded  in  the  war  have  been  fully  audited,  whatever  sum  may  be 
left  shall  be  deposited  with  the  Guaranty  Fund,^  established  in  con- 
nection with  industrial  accidents  by  article  24  of  the  law  of  April  9, 
1898.     Paris,  November  25,  1916.' 

"A  somewhat  earlier  law,  passed  April  17,  1916,  is  not  concerned 
with  compensation  for  accidents  but  with  reserving  certain  positions 
for  disabled  soldiers.  It  provides  that  a  number  of  government  po- 
sitions hitherto  reserved  for  non-commissioned  officers  with  a  certain 
length  of  service,  shall  during  five  years  after  the  cessation  of  the  war 
be  open  to  disabled  soldiers  of  all  ranks  irrespective  of  length  of  ser- 

1  Fonds  special  de  prevoyance  des  blesses  de  la  guerre. 

2  Ministre  du  travail  at  de  la  prevoyance  sociale. 
^  Caisse  des  depots  et  consignations. 

*  Loi  des  finances. 
^  Fonds  de  garantie. 


employees'  compensation  689 

vice,  preference  being  given  to  men  with  large  families;  and  that  in 
the  future  no  manufacturing  or  business  concern  shall  obtain  a  con- 
cession, monopoly,  or  subvention  from  the  State,  department,  or 
commune  unless  it  reserves  a  certain  number  of  positions  to  disabled 
soldiers.  With  regard  to  this  law,  Dr.  Bourrillon,  the  head  of  the  great 
re-educational  center  at  Saint-Maurice,  says  that  when  reserved  posi- 
tions are  granted  to  disabled  soldiers  preference  should  be  shown 
the  most  severely  wounded,  and  such  positions  should  not  be  given 
to  men  still  capable  of  entering  industry." 

Other  laws  have  been  proposed  but  have  not  been  passed,  namely: 

1.  A  law  making  vocational  re-education  compulsory; 

2.  A  law  making  it  obligatory  on  employees  of  any  number  of 
workmen  above  a  prescribed  minimum  to  employ  a  certain  proportion 
of  disabled  soldiers; 

3.  A  law  giving  to  disabled  soldiers  the  means  of  acquiring  a  piece 
of  land. 

Workmen's  compensation  and  other  forms  of  social  insurance  are 
still  in  their  infancy  in  this  country.  Undoubtedly  many  amendments 
to  the  existing  laws  and  the  enactment  of  new  ones  will  follow  in  the 
wake  of  the  social  democracy  which  is  developing  as  a  result  of  this  war. 
The  surgeon  in  industry  because  of  his  knowledge  gained  from  actual 
experience  in  handling  these  problems  must  play  an  important  part 
in  moulding  these  changes. 


CHAPTER  XLII 
COlVtPENSABLE  HERNIA 

The  condition  known  as  traumatic  hernia  is  strongly  denied  by 
some  and  just  as  forcibly  affirmed'  by  others.  Few  subjects  connected 
with  industrial  surgery  have  caused  greater  discussions  among  sur- 
geons especially  since  the  enactment  of  employees  compensation  laws 
in  this  country.  In  Germany  and  England  the  passage  of  compensa- 
tion laws  created  similar  discussions.  It  seems  that  following  the 
creation  of  these  employees  compensation  acts  claims  for  traumatic 
hernias  have  greatly  increased  both  in  Europe  and  in  this  country. 
Some  of  the  best  surgeons  have  used  this  fact  to  try  and  prove  that: 
(1)  Industrial  compensation  commissions  are  biased  in  favor  of  the 
employee  and  are  rendering  erroneous  and  unjust  claims  when  they 
grant  compensation  for  this  condition;  (2)  that  employees  are  inten- 
tionally making  fraudulent  claims  when  they  swear  that  their  hernias 
were  due  to  accident  or  extreme  effort;  (3)  that  surgeons  who  claim 
that  hernia  can  result  from  trauma  or  severe  efforts  are  unscientific 
and  differ  from  the  ''decisions  of  established  medicine." 

Surgeons  who  hold  the  above  views  seem  to  forget  that  these  de- 
cisions of  established  medicine  date  back  to  the  precompensation  days 
and  were  based  on  the  testimony  of  expert  authority,  made  in  the 
courts  of  England  especially,  and  later  in  our  own  courts,  to  the  effect 
that  a  traumatic  hernia  could  only  occur  from  a  direct  violence  re- 
sulting in  a  definite  tearing  or  rupture  of  the  abdominal  wall.  All 
other  hernias  were  claimed  to  be  due  to  congenital  defects,  preformed 
sacs,  and  were  similar  to  all  other  diseases  which  might  occur  coinci- 
dental with  occupation  but  not  related  to  it.  Such  testimony  was 
sustained  by  practically  every  court  and  their  views  were  considered 
as  the  decisions  of  established  medicine.  Any  surgeon  holding  a  dif- 
ferent view  was  unorthodox.  It  was  useless  for  an  employee  to  seek 
compensation  for  his  hernia  the  result  of  occupation  when  these  legal 
and  medical  forces  were  aligned  against  him.  Naturally  few  claims 
for  traumatic  hernia  were  made,  although  employees  in  those  days, 
just  as  frequently  blamed  their  work  for  the  condition  as  at  the  pres- 
ent time. 

A  new  viewpoint  began  to  permeate  industry  during  the  first  ten 
years  of  the  present  century.  It  was  characterized  by  greater  con- 
sideration of  the  rights  of  the  working  man  by  his  employer,  a  more 
humane  attitude,  which  took  into  account  certain  moral  responsi- 

690 


COMPENSABLE   HEENIA  691 

bilities  not  included  in  the  purely  legal  obligations.  No  greater  proof 
of  this  change  could  be  furnished  than  the  passing  of  the  old-time  com- 
pany doctor,  who  constantly  favored  the  legal  rights  of  his  employer 
as  opposed  to  the  moral  rights  of  the  employee,  and  his  replacement 
by  the  medical  staffs,  maintained  by  many  of  our  best  and  largest 
industries,  whose  duties  consist  of  health  supervision,  prevention  and 
the  best  medical  and  surgical  care  of  the  employees.  No  laws  have 
forced  these  changes;  the  pioneer  systems  of  industrial  medicine  were 
established  before  the  enactment  of  compensation  laws. 

This  new  attitude  on  the  part  of  industry  is  exemplified  by  many 
other  changes.  Some  of  the  leading  concerns  organized  mutual  bene- 
fit associations  in  order  that  employees  might  receive  at  least  a  portion 
of  their  pay  during  a  period  of  disability;  group  insurance  was  inaugu- 
rated by  others  providing  insurance  against  death;  many  began  to  carry 
their  own  accident  insurance  realizing  that  thereby  more  equitable  com- 
pensation would  be  granted  to  their  injured  employees;  some  of  these 
paid  full  wages  during  disability,  and  a  generous  compensation  in  case 
of  injury,  although  legally  only  two-thirds  of  the  wages  were  required. 
Most  of  these  concerns  adopted  the  policy  of  "give  the  employee  the 
benefit  of  the  doubt."  Whenever  an  accident  occurred,  if  there  was 
any  moral  responsibility  attached,  even  though  legally  they  might 
side-step  the  laws,  compensation  and  free  surgical  care  were  given. 

This  policy  soon  extended  to  diseases.  When  a  disease  occurred 
which  might  be  traceable  to  some  occupational  cause,  free  medical 
service  and  compensation  were  furnished,  although  very  few  state  laws 
included  occupational  diseases  among  the  compensable  conditions. 
Certainly  no  responsibility  existed  for  the  majority  of  cases  of  bad 
teeth  or  poor  eyesight  and  yet  several  industries  furnished  free  den- 
tal care  and  oculist  services  to  their  people. 

The  question  of  legal  rights  did  not  enter  into  the  plans  of  these 
industries.  They  recognized  certain  moral  obligations  and  in  addi- 
tion realized  that  it  was  good  business  to  improve  the  conditions  of 
their  employees  and  thereby  make  them  more  useful  and  efficient. 

Among  such  broad-minded  employers  the  question  of  whether 
there  was  such  a  thing  as  traumatic  hernia,  for  which  they  could  be 
held  legally  responsible,  did  not  cause  much  concern.  They  were  not 
governed  by  the  decisions  of  established  medicine  nor  of  established 
law  but  based  their  decisions  upon  a  just  and  good  business  sense. 

If  they  employed  a  man  with  a  hernia  they  knew  the  industry 
was  not  responsible  for  it.  If  it  grew  gradually  worse  without  any 
definite  accident  or  excessive  occupational  effort  it  was  due  to  natural 
causes  and  again  they  were  not  responsible.  But  if  as  a  result  of  ac- 
cident or  severe  strain  this  hernia  became  strangulated,  at  once  doubt 
as  to  responsibility  entered  the  case  and  the  decision  was,  therefore, 


692  INDUSTRIAL    MEDICINE    AND    SURGERY 

rendered  in  favor  of  the  employee.  If  they  hired  a  man  who  showed 
no  sign  of  rupture  at  his  employment  examination,  but  who  later 
suffered  an  accident  or  a  severe  occupational  strain  and  as  a  result  the 
hernia  appeared,  compensation  and  free  surgical  care  were  given  be- 
cause in  the  man's  mind  the  accident  caused  the  trouble,  and  because 
they  recognized  that  to  a  certain  extent  the  occupation  was  contribu- 
tory to  the  final  development  of  the  condition. 

From  the  standpoint  of  efficiency  it  was  found  that  a  man  with 
hernia  was  about  25  per  cent,  less  efficient  than  the  man  without  one. 
Therefore,  these  concerns  might  refuse  to  employ  men  with  a  rup- 
ture but  they  became  more  and  more  liberal  regarding  the  repair  of 
such  a  condition  when  it  developed  in  an  old  employee. 

Such  was  the  attitude  of  several  concerns  at  the  time  of  the  pas- 
sage of  the  employees,  compensation  acts.  In  fact  these  very  laws 
were  an  expression  of  this  new  humane  influence  which  had  entered 
industry.  The  administration  of  these  acts  was  placed  in  the  hands 
of  industrial  commissions  whose  members  were  laymen  rather  than 
lawyers.  Influenced  by  the  generous  attitude  of  certain  industries, 
and  guided  by  this  sentiment  and  a  consideration  of  moral  rights,  com- 
bined with  their  meagre  legal  knowledge,  the  decisions  of  these  various 
commissions  were  often  at  variance  to  those  rendered  by  the  courts 
in  the  past. 

Thus  employees  began  to  seek  compensation  for  many  conditions 
which  heretofore  had  not  been  considered  compensable,  and  included 
among  these  were  hernias  which  developed  during  employment. 

The  honest  employee  who  claimed  that  his  hernia,  which  appeared 
shortly  after  an  accident  and  was,  therefore,  in  his  mind  due  to  the 
same,  was  not  seeking  fraudulent  compensation.  The  industrial  com- 
mission which  granted  his  claim  was  governed  only  by  a  spirit  of  square 
dealing.  The  surgeon  who  recognized  the  pre-existing  congenital 
defect,  or  the  preformed  sac,  and  yet  testified  that  the  accident 
must  have  been  a  contributing  factor  in  the  final  development  of  the 
hernia,  was  not  unscientific  or  unorthodox. 

The  question  of  traumatic  hernia,  therefore,  simmers  down  to  three 
considerations : 

1.  A  proper  definition  of  what  is  meant  by  traumatic  hernia; 

2.  To  what  extent  must  an  accident  or  an  occupational  hazard 
which  only  partially  contributes  to  the  development  of  a  condition 
be  held  responsible  for  the  same; 

3.  In  which  cases  should  compensation  be  paid  by  the  employer. 
The  term  'traumatic  hernia"  as  used  by  most  authorities  covers 

only  a  small  percentage  of  the  compensable  cases.  These  authorities 
consider  only  those  hernias  which  develop  immediately  following  a 
direct  violence  to  the  abdominal  wall  as  true  traumatic  hernias.     Some 


COMPENSABLE    HERNIA  693 

claim  that  this  violence  must  result  in  a  tearing  or  rupture  of  the  soft 
tissues  thus  allowing  some  portion  of  the  abdominal  viscera  to  pro- 
trude. Others  state  that  the  violence  must  be  sufficiently  severe  as 
to  give  signs  of  ecchymosis  and  swelUng  with  the  appearance  of  the 
hernias.  Practically  all  surgeons  agree  that  hernias  the  result  of  such 
violence  are  very  rare.  Therefore,  if  we  adopt  this  definition  of  trau- 
matic hernia  and  grant  compensation  only  to  this  type  of  case,  we 
have  practically  removed  the  problem  from  the  realm  of  discussion. 

However,  some  of  our  best  authorities  such  as  Coley,  Plummer, 
Colcord,  and  several  others  add  to  the  above  definition  of  traumatic 
hernia  by  including  those  cases  which  result  from  the  indirect  appli- 
cation of  force  causing  greatly  increased  intra-abdominal  pressure. 
Thus  Coley  says:  "We  would  define  traumatic  hernia  as  a  hernia 
resulting  from  the  direct  application  of  force  to  that  portion  of  the 
abdominal  wall  at  which  the  hernia  appears,  or  a  hernia  resulting 
from  the  indirect  application  of  force  causing  greatly  increased  intra- 
abdominal pressure.  Whether  the  hernia  follows  the  natural  openings 
in  the  abdomen,  inguinal  or  crural  canals,  or  creates  a  new  passageway 
is  immaterial."  Therefore,  if  we  adopt  this  broader  definition  of 
traumatic  hernia  we  at  once  admit  many  additional  hernias  to  the 
compensable  class. 

The  amount  of  violence  or  force  necessary  to  produce  a  traumatic 
hernia  as  above  defined  is  another  important  factor  in  our  definition. 
Some  surgeons  claim  that  a  violence  or  force  sufficient  to  produce  a 
hernia  will  also  produce  tearing  of  the  soft  tissues,  ecchymosis  and 
swelling;  such  signs  may  not  always  appear  externally  but  will  certainly 
be  found  on  operation,  evidenced  by  a  reddened,  inflamed  peri- 
toneum and  swollen  soft  parts.  Other  surgeons  agree  that  a  hernia 
the  result  of  direct  violence  will  show  these  signs  of  injury  while  other 
hernias  due  to  increased  intra-abdominal  pressure  may  not  develop 
signs  of  a  recent  trauma  but  will  always  give  symptoms  such  as  pain 
and  tenderness  followed  immediately  or  within  a  few  hours  by  the 
appearance  of  the  rupture.  The  English  Court  of  Appeals  and  several 
of  our  industrial  boards,  especially  Illinois,  Wisconsin,  Michigan  and 
New  York,  have  ruled  that  "where  a  strain  causes  a  protrusion  of 
the  bowels  it  is  a  compensable  injury,  even  though  the  protrusion  is  at 
a  point  weakened  by  congenital  malformation  or  pre-existing  hernia." 

Therefore,  it  is  quite  evident  that  the  question  of  the  degree  of 
violence  and  force  necessary  to  produce  "traumatic  hernia"  is  the 
real  bone  of  contention.  If  we  accept  the  view  of  many  excellent 
surgeons  that  traumatic  hernia  can  only  result  from  direct  violence  to 
the  abdominal  wall,  we  then  eliminate  many  hernias  which  are  being 
compensated  to-day.  If  we  include  in  the  above  class  those  hernias 
which  result  from  increased  intra-abdominal  pressure  due  only  to 


694  INDUSTRIAL    MEDICINE    AND    SURGERY 

indirect  application  of  force  to  the  abdominal  wall,  we  extend  com- 
pensation to  a  greater  number  of  hernias  and  at  once  begin  to  confuse 
the  issue.  If  we  still  further  include  in  our  list  of  .traumatic  hernias 
all  those  which  develop  from  other  forms  of  indirect  application  of 
force,  such  as  a  sudden  strain  causing  greatly  increased  abdominal 
pressure,  we  have  admitted  still  a  larger  group  to  the  compensable 
class.  And  finally  if  we  agree  with  those  legal  opinions  which  include 
all  hernias  developing  as  a  result  of  strain,  without  defining  the  degree 
of  strain,  then  we  have  thrown  the  gates  wide  open  and  will  pay  com- 
pensation to  a  large  percentage  of  all  hernias  which  develop. 

Those  surgeons  who  claim  that  only  the  true  traumatic  hernia  is 
compensable  do  a  great  injustice  to  many  employees.  Those  industrial 
commissions  which  claim  that  all  hernias  developing  as  a  result  of 
*' strain"  are  compensable,  do  a  great  injustice  to  the  employers.  Both 
views  are  responsible  for  many  of  the  fraudulent  claims  made  for  com- 
pensation by  dishonest  employees. 

Traumatic  hernia  is  a  misnomer  as  it  indicates  the  very  small  group 
of  hernias  resulting  from  direct  violence.  Other  types  of  hernia  de- 
velop for  which  the  occupation  is  more  or  less  responsible  and  are 
described  by  Lotheissem  and  other  German  writers  as  "accidental 
hernia." 

I  wish  to  adovcate,  therefore,  that  the  term  "compensable  hernia" 
be  adopted  in  this  country  by  both  the  medical  and  legal  professions; 
and  further,  that  this  term  shall  include  all  cases  of  true  "traumatic 
hernia"  and  all  cases  of  "accidental  hernia"  in  which  the  force  causing 
their  development  is  directly  the  result  of  some  unnatural  occupa- 
tional hazard. 

Under  this  definition,  the  following  would  be  compensable  hernias : 

1.  True  Traumatic  Hernia. — (a)  As  a  result  of  direct  violence  all 
parts  of  the  hernia  show  signs  of  being  recently  formed.  Such  a 
hernia  develops  immediately,  or  within  a  very  short  time  after  the  re- 
ceipt of  the  injury.  It  is  accompanied  with  definite  signs  of  injury  to 
the  soft  tissues  at  the  point  where  the  hernia  appears. 

Example. — Man  struck  in  the  right  groin  by  the  sharp  end  of  a  crow- 
bar thrown  forcibly  by  a  fellow  employee.  Severe  bruising,  and 
ecchymosis  resulted.  Patient  complained  of  severe  pain  and  nausea 
and  within  ten  hours  a  definite  direct  inguinal  hernia  appeared. 

(6)  As  a  result  of  direct  violence  to  some  other  portion  of  the  ab- 
dominal wall  an  indirect  force  is  established  through  the  medium  of 
the  increased  intra-abdominal  pressure  and  causes  a  hernia  to  appear 
immediately  or  very  shortly  afterward,  usually  at  one  of  the  natural 
openings  in  the  abdomen.  The  presence  of  a  predisposition  for  her- 
nia such  as  a  congenital  defect  or  a  preformed  sac,  "is  immaterial." 
All  that  is  necessary  to  know  is  that  the  hernia  did  not  already  exist. 


COMPENSABLE    HERNIA  695 

Such  a  hernia  nmy  or  may  not  present  external  signs  of  injury  at 
the  point  of  development,  such  as  ecchymosis  or  swelling,  but  prac- 
tically always  gives  definite  symptoms,  such  as  pain,  tenderness  and 
nausea. 

Example. — A  boy  was  run  over  by  an  automobile,  the  wheel  pass- 
ing directly  across  the  middle  of  his  abdomen.  He  was  immediately 
examined  and  signs  of  severe  contusion  extending  completely  across 
the  abdominal  wall  were  found.  Careful  examination  for  hernia  failed 
to  reveal  any  sign  of  this  condition.  Twelve  hours  later  a  small  in- 
direct left  inguinal  hernia,  the  size  of  a  pigeon's  egg,  appeared  and  was 
accompanied  with  severe  pain  and  tenderness.  There  was  no  sign  of 
direct  violence  at  this  point  but  the  indirect  force  was  held  responsible. 

(c)  As  a  result  of  direct  violence  to  some  other  part  of  the  body 
other  than  the  abdomen,  a  hernia  appears  the  result  of  the  indirect 
application  of  force  which  causes  greatly  increased  intra-abdominal 
pressure.  Such  a  hernia  appears  immediately  or  shortly  afterwards, 
always  at  one  of  the  natural  openings  in  the  abdomen,  usually  the  in- 
guinal canal.  Such  a  hernia  rarely  gives  external  signs  of  injury  but 
as  a  rule  causes  the  employee  to  complain  of  pain  in  the  inguinal  re- 
gion and  often  nausea,  immediately  following  the  violence.  Here 
again  the  question  of  predisposition  to  hernia  is  immaterial  but  it  is 
essential  to  know  whether  a  fully  estabhshed  hernia  was  existent  or 
not.  The  burden  of  proof  rests  with  the  employer,  hence  the  impor- 
tance of  careful  physical  examinations  with  accurate  records  for  all 
employees. 

Example  No.  1. — A  negro  examined  two  years  previously,  no  hernia 
present,  was  carrying  a  heavy  desk  with  three  other  men.  His  partner 
fell  thus  throwing  all  the  weight  of  the  end  of  the  desk  on  this  employee. 
He  immediately  felt  pain  in  his  right  inguinal  region  and  became  quite 
sick  at  his  stomach.  He  rested  for  fifteen  minutes  and  then  started 
to  work  again.  Three  hours  later  while  in  the  toilet  he  noticed  a 
slight  swelUng  in  the  groin  and  reported  to  the  doctor's  office.  An 
examination  showed  a  hernia  within  the  inguinal  canal  and  about  the 
size  of  a  walnut.  It  was  tender  on  manipulation  but  could  be  readily 
reduced.  There  were  no  signs  of  ecchymosis  or  swelling  of  the  tissues 
about  the  hernia  but  the  former  record,  history  of  accident,  immediate 
symptoms,  and  appearance  of  a  small  hernia,  placed  this  in  the 
compensable  class. 

Example  No.  2. — An  employee  pushing  a  heavy,,  loaded  truck 
sHpped  on  an  iron  runway,  causing  him  to  fall  forward,  the  weight  of  the 
truck  adding  to  the  force  of  the  fall.  He  immediately  felt  a  pain  in  the 
right  inguinal  region  which  increased  when  he  attempted  to  again  push 
the  truck.  He  complained  of  the  condition  to  his  helper  and  the  latter 
took  charge  of  the  truck.     This  employee  finished  his  day's  work  but 


696  INDUSTRIAL    MEDICINE    AND    SURGERY 

"took  it  easy."  That  night  while  taking  a  bath,  he  noticed  a  small 
swelhng  in  his  right  groin.  The  next  morning  he  reported  to  the  doc- 
tor's office.  Examination  showed  a  small  indirect  inguinal  hernia 
the  size  of  a  walnut.  The  man's  record  showed  that  he  had  been  ex- 
amined for  employment  four  years  previously  and  no  hernia  was  present. 
He  was  again  thoroughly  examined  a  year  before  this  accident  without 
a  hernia  being  discovered.  This  record,  history  of  the  injury,  and  the 
fact  that  he  complained  to  his  helper  placed  this  hernia  in  the  compen- 
sable group. 

(d)  As  a  result  of  any  of  the  forces  described  in  (a),  (h),  or  (c),  a  man 
known  to  have  a  hernia  or  who  gives  a  history  of  a  hernia,  suffers  some 
complication  such  as  strangulation,  incarceration  or  hemorrhage  into 
the  sac.  While  his  occupation  may  not  be  responsible  for  the  hernia, 
yet  the  accident  was  responsible  for  the  complication  and,  therefore, 
is  a  compensable  condition. 

Example. — A  packer  with  a  known  hernia  poorly  protected  by  a 
truss  was  helping  load  a  heavy  box  on  to  a  truck.  Standing  on  the  truck 
he  was  leaning  over  lifting  up  the  box  when  the  truck  moved  forward, 
causing  the  weight  of  the  box  to  be  suddenly  thrown  on  the  employee 
and  he  fell  forward  to  the  ground.  He  immediately  complained  that 
his  rupture  had  come  down  and  endeavored  to  replace  it.  Failing  in 
this,  he  reported  to  the  doctor's  office  where  every  effort  was  made  to 
reduce  the  contents  of  the  hernia  but  without  success.  The  man  com- 
plained of  extreme  pain  and  a  short  time  later  began  to  vomit.  The 
swelling  increased  in  size  and  after  a  few  hours  it  was  quite  evident  that 
a  strangulation  had  developed  in  the  hernia.  An  operation  was  per- 
formed at  once  and  the  strangulation  reheved  followed  by  the  repair 
of  the  hernia. 

2.  "Accidental  Hernia"  or  "Sudden  Hernia." — This  group  includes 
those  hernias  which  appear  immediately  or  shortly  after  a  sHght  ac- 
cident occurring  coincidental  with  severe  straining;  or  as  the  result  of  a 
severe  occupational  strain  out  of  all  proportion  to  the  lifting  and  strain- 
ing of  ordinary  occupation. 

The  great  majority  of  hernias  develop  slowly,  "the  gradual  dila- 
tation by  mesentery  of  a  preformed  sac."  The  congenital  defect  or 
predisposition  is  the  chief  cause  for  such  hernias  and  the  relation  of 
natural  occupation  or  of  the  natural  acts  of  ordinary  life  are  immaterial 
in  their  formation.  These  correspond  to  the  gradual  development 
of  "flat-foot"  a  result  of  faulty  shoes,  constant  standing  and  walking 
or  other  natural  causes;  or  to  the  development  of  tuberculosis  in  em- 
ployees engaged  in  occupations  which  in  no  wise  predisposed  to  this 
condition. 

A  small  percentage  of  these  hernias,  however,  make  their  first  ap- 
pearance after  some  unnatural  occupational  hazard  which  is  out  of 


COMPENSABLE    HERNIA  697 

all  proportion  to  these  ordinary  or  natural  conditions.  These  corre- 
spond to  the  occupational  diseases  which  are  now  recognized  in  some 
states  as  accidental  and,  therefore,  compensable.  These  are  border- 
line cases  for  which  no  hard  and  fast  rules  can  be  laid  down.  The 
individual  merits  of  each  case  must  be  carefully  considered  to  arrive 
at  an  equitable  settlement. 

Example  No.  1. — A  young  man  of  rather  slight  build  who  had  done 
nothing  but  clerical  work,  sought  employment  in  another  concern. 
He  was  given  a  physical  examination  and  no  hernia  was  found.  He 
was  assigned  to  the  dry  goods  department.  A  month  later  he 
endeavored  to  lift  a  crate  containing  cotton  goods,  and  weighing 
about  150  pounds,  on  to  a  shelf  about  the  height  of  his  shoulders. 
He  tugged  and  strained  at  the  load  until  he  finally  had  it  in  place. 
He  immediately  felt  nauseated  and  faint  and  complained  of  pain  in 
his  lower  abdomen.  His  foreman  remonstrated  with  him  for  lifting 
such  a  heavy  package  and  told  him  to  rest  for  a  while.  As  he  con- 
tinued to  feel  badly,  the  foreman  finally  sent  him  to  the  doctor's 
office.  Examination  showed  a  distinct  bulging  of  the  right  inguinal 
canal  which  increased  on  coughing  and  straining  and  was  accompanied 
with  a  definite  impulse.  The  employee  was  sent  home  and  told  to 
report  the  next  day.  At  this  examination  it  was  evident  that  the  man 
was  suffering  from  a  direct  inguinal  hernia.  All  symptoms  had  dis- 
appeared except  that  he  complained  of  a  feeling  of  weakness  in  his 
side.  This  was  considered  a  compensable  hernia  and  as  such  was 
operated,  the  man  receiving  compensation  during  the  period  of  his 
disabihty. 

Example  No.  2. — This  employee,  46  years  old,  had  not  been  pre- 
viously examined  and,  therefore,  no  record  as  to  hernial  condition 
existed.  He  was  engaged  in  unloading  large  rolls  of  paper  from  a  car, 
the  rolls  weighing  200  pounds  each.  One  of  these  rolls  started  to 
fall  from  the  gangway  and  while  making  an  extreme  effort  to  pull 
it  back  in  place,  the  employee  fell  from  the  gangway  to  the  ground, 
a  distance  of  five  feet.  No  one  witnessed  the  accident  but  the 
employee  immediately  reported  to  his  foreman  and  told  him  that  he 
had  strained  his  side  in  falhng.  The  roll  of  paper  on  the  ground 
substantiated  his  statements.  He  was  at  once  sent  to  the  doctor's 
office.  Examination  failed  to  reveal  any  signs  of  external  injury 
and  no  fully  developed  hernia  was  found  although  a  slight  impulse  in 
the  inguinal  canal  was  obtained  on  coughing  and  straining.  He  was 
allowed  to  return  to  work,  the  foreman  being  informed  to  give  him 
light  employment  for  the  rest  of  the  day.  The  next  morning  he 
was  again  examined  and  on  coughing  and  straining,  a  small  hernia 
the  size  of  an  English  walnut  appeared  at  the  external  ring.  This 
patient  complained  of  a  low-grade  pain  made  worse  on  examination 


698  INDUSTRIAL   MEDICINE    AND    SURGERY 

of  the  hernia.  He  claimed  that  he  had  never  been  ruptured  before 
and  the  general  appearance  of  the  hernia  in  a  man  with  very  strong 
abdominal  muscles  seemed  to  indicate  its  recent  development.  All 
surgeons  will  agree  that  a  hernial  sac  sufficiently  long  to  allow  this 
hernia  to  appear  at  the  external  ring,  must  undoubtedly  have  been 
preformed.  Nevertheless,  the  history  of  the  unnatural  Qccupational 
hazard  was  so  definite,  there  were  no  witnesses  to  deny  the  accident, 
and  the  rapid  appearance  of  the  hernia  during  the  period  between 
the  two  examinations,  all  clearly  indicated  that  this  was  a  compensable 
hernia. 

In  the  first  group  of  compensable  hernias,  namely,  the  true 
"traumatic,"  the  question  of  the  congenital  defect  or  predisposition  is 
immaterial  as  both  Coley  and  Colcord  have  so  thoroughly  demon- 
strated. In  the  second  group,  namely,  the  "accidental"  or  "sudden" 
hernia,  the  decision  as  to  the  responsibility  for  the  condition  must 
depend  upon  two  causes — the  pre-existing  defect  and  the  exciting 
contributing  factor  that  makes  the  hernia  appear.  Every  bit  of 
evidence  which  can  be  collected  in  favor  of  one  or  the  other  of  these 
causes  must  be  carefully  weighed  before  deciding  whether  the  hernia 
was  due  to  "natural"  causes  or  whether  it  was  due  to  "unnatural" 
causes  and,  therefore,  compensable. 

In  favor  of  the  hernia  being  due  to  natural  causes,  we  have  the 
following : 

1.  History  or  knowledge  of  a  hernia  already  existing.  This 
implies  at  once  the  necessity  of  thoroughly  examining  all  applicants 
for  work  and  all  old  employees,  and  carefully  recording  the  presence 
or  absence  of  hernia. 

2.  History  of  a  hernia  in  childhood  which  was  apparently  cured 
by  a  truss  and  had  not  been  present  for  several  years. 

3.  Presence  of  an  undescended  testicle,  hydrocele,  or  of  lipomata 
in  the  inguinal  canal.  (Dr.  Kellogg  Speed  in  Surgery,  Gynecology  and 
Obstetrics,  September,  1914,  reports  in  154  herniotomies,  hpomata 
found  in  the  canal  in  47  4/10  per  cent,  of  his  cases.  Plummer  thinks 
this  an  important  predisposing  factor.) 

4.  Presence  of  hernia  at  some  other  abdominal  orifice  showing 
a  tendency  for  this  condition. 

5.  Weakness  of  the  structures  forming  the  walls  of  the  inguinal 
canal.  Moschcowitz  lays  considerable  stress  on  this  hypoplasia  of  the 
tissues  as  a  marked  predisposing  factor  to  hernia.  He  considers  this 
hypoplasia  is  not  Hmited  to  the  abdominal  muscles  alone  but  includes 
the  mesenteric  attachments.  He  assumes  that  if  one  or  more  of  these 
structures  has  been  weakened,  either  by  disease  or  by  some  atrophic 
process  thus  allowing  a  sagging  of  the  viscera  to  a  lower  level,  this  often 
results  in  hernia.     He  states  that  this  is  perhaps  an  excellent  way  to 


COMPENSABLE    HERNIA  699 

account  for  the  fact  that  it  is  not  the  blacksmith  or  hard  working 
laborer  who  most  frequently  acquires  a  hernia,  but  the  ill-nourished 
man  of  sedentary  habits.  The  experience  of  most  industrial  surgeons 
refutes  this  last  statement  however.  Scherechewsky  found  in  the 
examination  of  1200  steel  workers  that  ten  per  cent,  had  hernias, 
whereas  only  three  per  cent,  of  the  male  garment  workers  he  examined 
were  thus  afflicted,  Nathan  Jones  found  approximately  ten  per  cent, 
of  hernias  among  the  employees  he  examined,  most  of  whom  were 
engaged  in  very  heavy  occupations;  whereas  the  author  found  only 
two  and  six-tenths  per  cent,  of  the  employees  he  examined  had  hernias 
and  sixty  per  cent,  of  this  group  were  engaged  in  sedentary  or  light 
occupations. 

6.  A  large  external  inguinal  ring  is  given  by  most  authorities  as 
evidence  of  a  predisposition  to  hernia.  Colcord  states,  however,  that 
he  examined  6000  men,  taking  great  care  to  examine  the  condition  of 
the  external  and  internal  ring  of  the  inguinal  canal.  He  found  500 
cases  of  open  rings  among  these  6000  men.  Twenty-five  cases  of  hernia 
developed  in  this  entire  group  but  not  one  of  those  25  hernias  occurred 
among  those  with  recorded  open  rings.  He  states  "not  one  of  the  500 
cases  of  open  rings  has,  to  my  knowledge,  developed  a  hernia."  Plum- 
mer,  Lauffer,  Hopkins  and  others  place  great  stress  upon  this  enlarged 
ring.  On  the  other  hand,  I  have  operated  on  160  cases  of  hernia  which 
were  not  present  at  the  time  of  examination  for  employment.  Large 
rings  were  recorded  when  present  in  each  case  although  they  were  con- 
sidered immaterial.  A  man  either  had  a  hernia  or  he  did  not  have  it; 
the  presence  of  a  large  ring  was  not  considered  evidence  of  a  potential 
hernia.  In  fact,  the  large  ring  enabled  us  to  make  a  better  and  more 
thorough  examination  of  the  inguinal  canal.  In  the  160  operations 
only  one  of  the  cases  showed  a  recorded  large  external  ring  at  the  time 
of  employment.  I  have  never  been  able  to  definitely  diagnose  a  large 
internal  ring  without  finding  a  hernia  present.  Of  greater  importance 
is  the  bulging  of  the  inguinal  canal  between  the  internal  and  external 
rings  showing  a  predisposition  to  direct  inguinal  hernia. 

7.  A  family  history  of  hernia  is  a  strong  etiologic  factor  in  favor 
of  the  employee  being  congenitally  predisposed  to  the  condition.  I 
have  found  several  employees  claiming  that  their  hernias  had  de- 
velopesd  as  a  result  of  lifting  or  some  other  strain.  On  examination, 
fairly  well  developed  hernias  were  found.  On  careful  questioning  it 
was  learned  that  the  father,  grandfather,  one  or  two  uncles  and  a 
brother  all  had  hernias.  This  family  history  combined  with  the 
absence  of  a  definite  unnatural  causative  agent  forced  the  decision  that 
such  hernias  were  due  to  natural  causes. 

8.  The  age  of  the  patient  is  an  important  factor  in  determining  the 
natural  or  unnatural  cause  of  the  hernia.     Berger  in  an  analysis  of 


700  INDUSTRIAL    MEDICINE    AND    SURGERY 

10,000  cases  showed  that  the  highest  hernia  rate  occurred  during  the 
first  five  years  of  Hfe  due  almost  entirely  to  congenital  defects.  From 
five  to  thirty  years  of  age  there  is  a  rapid  fall  in  the  hernia  rate.  It 
then  begins  to  increase  reaching  its  second  highest  rate  at  the  age  of 
fifty-five.  From  fifty-five  to  seventy,  hernias  are  common  although 
less  than  one-haK  as  frequent  as  in  childhood.  Therefore,  a  hernia 
occurring  in  children  can  usually  be  traced  to  natural  causes;  and  when 
occurring  in  the  old  they  are  likewise  most  probably  due  to  natural 
causes,  chiefly  hypoplastic  condition  of  the  tissues  due  to  senility. 
Hopkins  has  pointed  out  that  hernias  are  very  common  among 
foreigners  especially  the  Greeks  and  the  Southern  Italians.  It  is  well 
known  that  these  foreigners  develop  a  premature  senility  which  un- 
doubtedly accounts  for  the  upward  curve  in  the  hernia  rate  from  ages 
thirty  to  fifty-five.  Colcord  accounts  for  these  by  the  condition  which 
he  describes  as  presenility  and  beheves  that  continued  hard  labor,  plus 
excesses  in  drink,  plus  poor  food,  plus  bad  hygienic  conditions,  all 
contribute  to  the  weakening  of  the  abdominal  walls.  These  conditions 
with  heredity  and  such  diseases  as  tuberculosis  and  syphilis  bring  on 
the  presenility  condition. 

9.  Other  etiologic  factors,  such  as  recent  debilitating  diseases, 
bronchitis,  prolonged  constipation,  faulty  posture,  visceroptosis,  etc., 
must  have  considerable  weight  in  favor  of  natural  causes  for  the 
hernia.  Lauffer  says  that  the  exciting  factor  in  hernia  is  some  oft- 
repeated  increase  in  the  intra-abdominal  tension  and  that  inguinal 
hernias  are  always  due  to  anatomic  defects,  plus  these  exciting  factors 
except  only  in  those  hernias  which  develop  at  the  point  where  direct 
traumatizing  force  has  been  applied.  He  designates  only  those  due 
to  direct  violence  as  traumatic  hernia,  and  calls  all  others  "latent 
hernia"  due  to  these  natural  causes. 

10.  Certain  conditions  found  on  examination  of  the  hernia  would 
indicate  that  it  was  due  to  natural  causes.  For  example,  a  large 
hernia  indicates  its  pre-existence ;  a  discoloration  or  deep  depression  of 
the  skin  over. the  hernia  indicates  that  a  truss  has  been  worn  and, 
therefore,  a  hernia  must  have  existed. 

11.  Conditions  found  at  the  operation  will  often  indicate  that  the 
hernia  was  of  long  standing  and,  therefore,  not  due  to  the  alleged 
injury,  for  instance,  a  thickened  well-formed  peritoneal  sac,  adherent 
mesentery  or  intestine  within  the  sac,  two  or  three  sacs,  the  "pan- 
taloon hernia,"  and  other  such  signs  of  an  old  condition.  C.  H.  Mayo 
says  that  heavy  fibrous  bands  found  in  the  hernial  sac  is  positive  proof 
of  a  long  standing  condition. 

In  favor  of  the  hernia  being  due  to  "unnatural  causes,"  we  have  the 
following : 

1.  Definite  proof  that  the  hernia  did  not  exist  previously.     Such 


COMPENSABLE    HERNIA  701 

proof  may  be  obtained  from  the  records  of  the  employee's  previous 
examination,  or  may  be  sworn  to  by  his  family  physician  or  relatives. 
Frequently  a  life  insurance  examination  may  be  referred  to  as  proof 
of  the  non-existence  of  the  hernia  if  examination  of  the  insurance 
record  fails  to  show  any  hernia  recorded.  All  insurance  examinations 
should,  therefore,  be  made  very  thoroughly  and  should  be  considered  as 
possible  medicolegal  evidence  later  on.  The  burden  of  proof  of  a 
pre-existing  hernia  rests  with  the  employer. 

2.  A  definite  history  of  an  accident  occurring  coincidental  with 
straining  or  of  a  severe  effort  far  in  excess  of  that  which  the  man's 
muscular  development,  stature  or  past  experience  in  the  occupation 
should,  call  for.  Such  factors  would  compose  the  unnatural  occupa- 
tional hazards  as  opposed  to  the  natural  strains  of  his  ordinary  work. 

3.  The  appearance  of  the  hernia  immediately,  or  very  shortly, 
after  the  occurrence  of  one  of  these  unnatural  exciting  causes.  This 
sudden  appearance  is  usually  evidenced  by  the  employee  complain- 
ing of  pain,  reporting  the  condition  at  once  to  one  or  more  fellow  em- 
ployees and  seeking  medical  attention  very  shortly  afterward. 

4.  The  examination  of  the  hernia  revealing  that  it  is  of  small  size, 
seldom  as  large  as  an  egg,  usually  within  the  canal  or  just  appearing 
at  the  external  opening.  Recently  formed  compensable  hernias  are 
never  of  large  size  no  matter  at  what  abdominal  orifice  they  appear, 
except  rarely  in  the  true  traumatic  type.  Real  pain  and  tenderness 
on  examination  are  usually  complained  of  by  the  patient. 

5.  At  operation  the  peritoneal  sac  is,  small,  very  thin,  and  seldom 
protrudes  the  entire  length  of  the  canal.  Adhesions  of  the  mesentery 
or  viscera  to  the  sac  are  never  present.  Old  hernial  sacs  are  dense, 
give  a  characteristic  pearly  appearance  and  are  often  difiicult  to  peal 
away  form  the  spermatic  chord  and  vessels,  whereas  the  recent  sac 
gives  a  less  characteristic  pearly  appearance  and  can  be  readily  freed 
from  the  chord.  In  direct  inguinal  hernia  a  definite  sac  may  not  be 
formed,  the  peritoneum  simply  bulging  into  the  weak  spot.  Repair 
of  these  hernias  can  often  be  made  without  opening  the  peritoneum. 

6.  The  final  decision  as  to  whether  a  given  hernia  is  compensable 
or  not  often  must  depend  upon  the  findings  at  the  operation.  If  the 
hernial  sac  and  contents  show  these  signs  of  recent  development  weight 
must  be  given  to  the  employee's  claim.  On  the  other  hand  if  an  old 
adherent  sac  is  founds  it  is  positive  proof  of  the  pre-existence  of  the 
hernia. 

Dr.  A.  I.  Bouffleur,  Railway  Surgical  Journal,  1913,  vol,  xx,  page 
421,  gives  an  excellent  discussion  on  traumatic  hernia.  He  states: 
"Those  who  have  operated  on  many  hernias  within  a  short  time  after 
their  discovery,  have  found  that  the  patient's  history  as  to  when  the 
hernia  was  produced  is  of  absolutely  no  value,  in  that,  when  you  examine 


702  INDUSTRIAL    MEDICINE    AND    SURGERY 

one  which  the  patient  states  occurred  only  the  day  before  you  will  find 
a  large  patent  canal,  a  thickened  and  old  peritoneal  surface  that  shows 
that  it  has  existed  for  months  and  perhaps  years.  Whereas,  in  another 
instance  you  will  find  that  there  is  evidence  of  recent  injury  to  the  peri- 
toneal tissue. 

"Surgeons  employed  by  the  Northwestern  Hospital  Association 
have  decided  to  make  the  following  arrangements  with  the  employees : 

" '  If  upon  examination  at  operation  we  find  that  the  hernia  is  of 
congenital  type  or  the  tissues  have  the  appearance  of  rupture  having 
existed  for  a  long  time,  you  will  pay  for  it;  if  the  condition  has  the 
appearance  of  being  of  recent  origin  then  the  Association  will  stand 
the  expense.' 

"So  our  experience  of  this  problem  which  is  the  same  as  that  of 
the  Northern  Pacific,  where  similar  conditions  exist,  is  that  a  hernia 
which  appears  shortly  after  a  man  enters  the  service  and  becomes 
entitled  to  benefit  must  have  some  definite  evidences  of  being  of  recent 
occurrence,  such  as  locahzed  pain  or  nausea,  with  local  evidence  of 
traum'a  appearing  within  the  week,  or  upon  operation  there  must  be 
evidence  of  recent  rupture. " 

An  entirely  different  view  is  expressed  by  Dr.  John  J.  Moorhead 
in  the  Second  Bulletin  of  the  Transactions  of  American  Association 
of  Industrial  Physicians  and  Surgeons.  He  bases  his  conclusions  on  an 
analysis  of  the  operative  findings  in  150  cases  of  so-called  traumatic 
inguinal  hernia  and  states:  "These  operative  findings  then,  confirm 
the  opinion  that  so-called  traumatic  hernia  subjected  to  the  critical 
test  of  biopsy  or  anatomic  dissection  resembles  in  all  details  hernias 
acquired  in  the  ordinary  way. 

"  This  survey  also  indicates  that  injury  is  but  rarely  an  aggravating 
factor,  and  an  operator  in  the  absence  of  a  history  of  traumatism, 
would  be  unable  to  tell  from  the  findings  in  the  vast  majority  of  cases 
whether  or  not' trauma  featured  in  any  way." 

Dr.  Moorhead  states  that  "without  a  weak  canal  and  rings  at  birth, 
no  hernia  will  subsequently  form  unless  rings  and  canal  are  torn  asun- 
der or  weakened  by  some  external  or  internal  mechanism.  There 
is  from  birth  an  empty  sac  awaiting  contents,  and  this  sac  being 
continuous  with  that  larger  sac  in  the  abdomen,  will  sooner  or  later 
seek  an  occupant."  Such  a  sac  is  "an  invitation  for  a  resident  by 
virtue  of  its  empty  loneHness."  It  is  inconceivable  to  me  that  such 
a  sac  will  remain  completely  empty  during  the  tree  chmbing  days  of 
boyhood  and  the  more  strenuous  football  days  of  high  school  and  col- 
lege Hfe,  and  then  later  become  filled  with  omentum  and  intestines 
from  strains  not  half  as  strenuous.  These  congenital  sacs  are  early 
filled  with  their  occupant.  In  acquired  hernia  the  congenital  peri- 
toneal sac  may  not  have  been  completely  closed  off  and  gradually 


COMPENSABLE    HERNIA  '  703 

repeated  intra-abdominal  tension  forces  the  contents  into  such  a  sac, 
but  in  most  acquired  hernias  I  believe  the  peritoneal  sac  is  formed  dur- 
ing the  course  of  several  years  by  being  pushed  downward  from  the 
repeated  effort  of  the  abdominal  contents  to  enter  the  inguinal  canal. 
At  first  such  hernias  are  self-reducible,  the  change  taking  place  with- 
out the  knowledge  of  the  patient.  Later  on  when  the  patient  is  cogni- 
zant of  the  hernia  he  may  manually  reduce  the  contents  but  on  the 
slightest  exertion  the  sac  again  fills.  This  repeated  filling  of  the  sac 
causes  a  gradual  development  until  the  ordinary  large  acquired  hernia 
is  very  evident.  This  naturally  presupposes  that  the  internal  ring 
or  the  walls  of  the  canal  are  weakened  either  congenitally  or  from  some 
acquired  cause.  A  similar  weakness  is  present  in  the  case  of  a  recently 
acquired  hernia  following  some  severe  strain.  Examination  of  the 
sac,  therefore,  at  an  operation  performed  shortly  after  the  appearance 
of  the  hernia,  will  show  a  recent  bulging  of  the  peritoneum  through 
the  weak  spot  without  signs  of  tearing,  ecchymosis  or  inflamed  peri- 
toneum which  Moorhead  claims  must  always  be  present  if  the  sac  has 
just  formed. 

Therefore,  the  author  agrees  with  Dr.  BoufHeur  and  unreservedly 
states  that  a  small  recently  developed  peritoneal  sac  can  often  be 
demonstrated  at  operation. 

In  order  to  determine,  therefore,  whether  one  of  these  "accidental" 
or  ''sudden"  hernias  is  compensable  or  not,  the  surgeon  must  weigh 
very  carefully  all  the  evidence  in  favor  of  both  the  "natural  causes" 
and  the  "unnatural  causes."  If  the  former  predominate  the  em- 
ployer is  not  responsible,  but  if  the  latter  predominate  he  is  respon- 
sible and  under  our  present  compensation  acts  the  patient  should  be 
compensated. 

In  arriving  at  these  conclusions  the  author  has  given  the  weight- 
iest consideration  to  the  arguments  advanced  by  those  execellent 
surgeons  who  claim  that  a  true  traumatic  hernia  can  only  result  from 
the  direct  application  of  force  to  the  abdominal  wall  and,  therefore, 
only  these  rare  hernias  should  be  compensated.  He  has  also  con- 
sidered carefully  the  claims  of  the  others  that  any  strain  or  lifting 
which  causes  the  protrusion  of  the  abdominal  contents  or  the  com- 
pletion of  that  physical  condition  known  as  rupture,  should  be  com- 
pensated as  the  strain  was  the  contributing  factor  to  the  hernia.  I 
have  tried  to  demonstrate  that  most  of  the  contention  is  due  to  erro- 
neous use  of  the  term  "traumatic  hernia"  and  that  the  just  settlement 
of  these  cases  depends  upon  a  careful  consideration  of  the  moral  and 
legal  responsibiHties  in  each  individual  case. 

Thus  from  a  medicolegal  standpoint  all  hernias  can  be  divided 
into  two  great  classes,  namely:  compensable  and  non-compe'nsable. 
The  compensable  hernias  include:   (1)   The  true  traumatic,  and  (2) 


704  INDUSTRIAL    MEDICINE    AND    SURGERY 

the  accidental  or  sudden  hernias  developing  from  unnatural  occu- 
pational hazards.  Non-compensahle  hernias  include:  (1)  The  true 
congenital  hernias,  and  (2)  the  acquired  hernias  from  natural  causes. 

There  is  an  increasing  tendency  among  many  of  our  leading  cor- 
porations, especially  when  they  employ  a  surgeon,  to  operate  on  all 
cases  of  hernia  occurring  in  their  employ,  paying  the  expenses  of  the 
operation  and  compensation  for  the  period  of  disability.  Some  claim 
that  they  do  this  regardless  of  the  medicolegal  aspects  of  the  case. 
The  truth  is  that  most  of  these  concerns  know  that  a  hernia  did  not 
exist  at  the  time  of  employment  as  a  physical  examination  was  made 
and  if  the  applicant  happened  to  have  a  hernia  he  was  not  employed. 
Therefore,  when  an  employee  develops  a  hernia  during  the  course  of 
his  occupation  and  claims  that  some  accident  or  severe  effort  brought 
on  the  condition,  no  employer  can  honestly  state  that  the  alleged  injury- 
did  not  play  a  contributing  part  in  the  development  of  the  hernia.  It 
is  the  surgeon's  duty  to  carefully  analyze  all  such  cases  and  to  advise 
the  employer  which  ones  should  be  thus  compensated  and  which  ones 
are  not  deserving  of  compensation. 

The  author  recently  analyzed  from  his  records  135  cases  of  hernia 
which  were  found  among  the  old  employees  of  a  concern  which  dis- 
played a  very  generous  attitude  toward  such  cases. 

One  hundred  and  twenty  of  these  had  been  previously  examined  and 
records  showed  no  hernia  present.  Of  the  15  who  had  not  been  pre- 
viously examined,  4  had  had  the  hernias  since  boyhood,  8  said  the 
conditions  had  gradually  developed  and  3  claimed  it  had  been  due 
to  recent  injury. 

One  hundred  of  these  120  cases  claimed  or  thought  the  condition 
was  due  to  accident  or  thought  it  was  caused  by  heavy  work.  Great 
weight  must  be  given  to  these  claims  as  all  of  these  employees  were 
recorded  as  not  having  hernias  at  previous  examinations.  They 
were  all  carefully  considered  by  the  above  standards  for  compensable 
and  non-compensable  hernias. 

Thirty  of  these  were  definite  compensable  hernias,  and  were  operated 
and  paid  compensation. 

Twenty-two  were  borderline  cases  and  were,  therefore,  given  an 
operation  and  compensation. 

Forty-eight  were  not  considered  compensable  because  all  showed 
well-formed  hernias,  could  give  no  definite  history  of  some  unnatural 
cause,  had  not  reported  to  their  foreman  or  to  the  doctor  after  the 
alleged  strain;  in  other  words,  did  not  have  the  earmarks  of  a  "sudden" 
hernia  following  some  unnatural  occupational  hazard.  Twenty-one  of 
these  were  given  free  operations  but  no  compensation. 

At  the  operations  on  the  compensable  cases  the  entire  30  showed 
small,  recently  formed  sacs.     In  the  22  borderline  cases  only  4  showed 


COMPENSABLE    HERNIA  705 

recent  sacs.  The  remaining  18  showed  signs  of  an  old  hernial  sac 
which  had  evidently  been  closed  off  at  the  internal  ring  and  was 
recently  occupied  by  the  abdominal  contents,  or  showed  small  sacs 
with  fibrous  bands  and  even  adherent  mesentery.  In  these,  however, 
the  alleged  accident  had  undoubtedly  contributed  to  the  reappearance 
or  the  completion  of  an  existent  hernial  condition. 

In  the  21  cases  which  were  operated  but  were  not  considered  com- 
pensable, all  gave  definite  signs  of  a  hernial  sac  of  long  standing. 

The  average  age  of  these  100  cases  was  36  years.  The  youngest 
was  18  and  the  oldest  60  years. 

Two  of  the  cases  were  in  girls,  both  having  right  indirect  inguinal 
hernias.  Neither  of  these  cases  had  been  examined  previously  but 
the  history  and  indefinite  statements  as  to  cause  placed  them  in  the 
non-compensable  class  and  this  was  borne  out  at  the  operation. 

The  average  length  of  employment  was  43-^  years. 

Forty-five  were  engaged  in  very  heavy  occupations,  26  in 
moderately  heavy  occupations,  and  29  in  clerical  or  Hght  occupations. 

Of  the  entire  135  cases,  47  per  cent,  were  right  indirect  inguinal, 
36  per  cent,  left  indirect  inguinal,  10  per  cent,  double  indirect  inguinal, 
3  per  cent,  (all  compensable)  right  direct  inguinal,  2  per  cent,  double 
direct  inguinal,  1  per  cent,  epigastric,  and  1  per  cent,  femoral. 

My  analysis  has  been  limited  to  this  smaU  number  of  cases  because 
all  fall  within  that  group  which  has  caused  so  much  discussion  among 
surgeons,  namely,  the  "accidental"  hernias  and  the  borderhne  cases, 
with  rather  indefinite  history  of  causal  factor,  and  occurring  among 
employees  who  had  been  previously  examined  and  were  recorded  as 
having  no  hernias. 

After  examining  several  thousand  cases  of  hernias  and  after  operat- 
ing several  hundred,  I  have  only  seen  five  cases  of  true  traumatic 
hernia  due  to  direct  violence  at  the  point  where  the  hernias  developed. 
(1)  In  one,  the  man  was  struck  in  the  groin  by  a  crowbar;  (2)  a  brake- 
man  was  crushed  between  the  bumpers  of  two  cars  and  a  ventral 
hernia  appeared;  (3)  a  man  was  running  through  the  aisle  at  fire 
drill  and  struck  his  left  inguinal  and  scrotal  region  against  a  truck 
handle.  A  large  contused  area,  swelling  and  hemorrhage  into  the 
scrotum  immediately  followed.  Within  three  days  a  definite  left, 
direct  inguinal  hernia  appeared;  (4)  a  pregnant  woman  was  kicked 
in  her  left  lower  abdomen  by  her  husband  and  very  shortly  a  ven- 
tral hernia  appeared  and  naturally  increased  in  size  as  pregnancy 
developed;  (5)  a  cowboy  came  to  rny  clinic  with  two  enormous  oblique 
inguinal  hernias.  He  gave  a  history  of  some  two  years  previously 
having  had  a  horse,  he  was  riding,  rear  and  fall  over  backward 
pinning  him  beneath  the  saddle.  The  pommel  of  the  saddle  had 
crushed  into  his  lower  abdomen.     Immediately  there  was  bulging 

45 


706 


INDUSTRIAL   MEDICINE    AND    SURGERY 


in  both  groins  and  these  continued  until  they  had  reached  the  pres- 
ent size.  The  man  denied  any  sign  of  rupture  previous  to  the  accident. 
It  is  quite  evident  that  even  in  those  cases  of  inguinal  hernia 
following  direct  violence,  some  doubt  will  always  exist  as  to  the  possible 
presence  of  a  congenital  predisposition  for  hernia. 

Industrial  Commissions  all 
over  the  country  are  depending 
on  the  surgeons  in  industry  to 
arrive  at  a  just  and  equitable 
decision  concerning  this  subject 
of  compensable  hernia.  It  be- 
hooves us  to  drop  the  time- 
worn  discussions  about  "trau- 
matic hernia"  and  to  tell  them 
just  what  types  of  hernia  should 
be  compensated  and  what  ones 
should  not. 

The  first  essential  is  to  make 
a  careful  physical  examination 
of  all  employees  and  to  record 
those  who  have  real  or  potential 
hernias.  Whenever  a  hernia 
develops  in  one  of  these  em- 
ployees, who  was  recorded  not 
to  have  a  hernia,  a  careful 
analysis  of  his  case  must  be 
made  to  determine:  (1)  was  it 
entirely  due  to  pre-existing  de- 
fect? (2)  was  it  entirely  due  to- 
some  severe  direct  or  indirect 
violence?  (3)  was  a  latent  con- 
dition already  present  and  only  aggravated  by  the  unnatural  occupa- 
tional hazard?  (4)  was  it  due  entirely  to  natural  causes?  (5)  or 
was  it  due  to  a  combination  of  all  of  these,  and  if  so,  which  was  the 
most  responsible? 

Every  surgeon  must  then  keep  a  careful  record  of  his  methods 
of  determining  these  points.  Whenever  one  of  these  hernias  is 
operated  a  careful  description  of  the  condition  of  the  sac  and  contents 
must  be  made  with  a  view  of  determining  which  are  the  recently  formed 
hernias  and  which  are  old  conditions. 

From  all  these  records  it  will  be  possible  to  standardize  definite 
methods  of  justly  deciding  which  are  the  compensable  hernias. 


Fig.  197. — Double  traumatic  hernia  fol- 
lowing crushing  'injury,  claimed  to  have 
resulted  from  horse  falling  on  patient. 


CHAPTER  XLIII    ' 
THE   COINCIDENCE  OF  ACCIDENTS  AND  DISEASE 

Accidents  often  occur  to  employees  who  are  suffering  from  some 
existing  disease  or  who  have  some  pre-existing  disabihty.  These 
coincidental  conditions  present  many  perplexing  problems  to  the  surgeon 
in  industry.  He  inust  determine  to  what  extent  the  accident  is 
responsible  for  the  disability  and  to  what  extent  the  diseased  condition. 
He  must  decide  whether  or  not  the  pre-existing  condition  was  ag- 
gravated by  the  accident  or  whether  the  injury  was  comphcated 
by  the  already  existing  disease.  A  very  minor  accident  may  occur  and 
a  few  days  later  the  employee  may  die,  the  result  of  some  other  patho- 
logic state,  A  claim  may  be  filed  by  the  family  for  compensation 
for  this  death  and  here  the  surgeon  is  confronted  with  the  problem 
of  whether  or  not  the  minor  accident  was  a  contributing  factor  or 
merely  coincidental. 

The  author  has  faced  these  problems  many  times  and  the  manage- 
ment has  voluntarily  settled  the  cases  on  the  decision  arrived  at  by 
their  surgeon.  In  every  instance  where  there  was  a  possibility  of  the 
accident  being  responsible  the  employee  was  given  the  benefit  of  the 
doubt.  On  the  other  hand,  if  the  surgeon  was  convinced  that  the  man- 
agement was  not  responsible  in  any  way  the  claims  for  disability 
were  refused  and  in  the  very  few  cases  which  went  to  court  the  deci- 
sion of  the  surgeon  was  always  sustained. 

These  coincidental  conditions  can  best  be  illustrated  by  the  fol- 
lowing case  reports: 

Case  1. — F.  T.  (male — 23  years  old)  employed  as  a  packer,  had 
worked  regularly  at  this  job  every  day  for  the  past  year.  On  Maj^ 
21,  1914,  he  stumbled  over  a  box  while  employed  and  fell  forward, 
striking  the  floor  with  his  outstretched  hands.  He  immediately 
felt  pain  in  his  right  wrist  and  had  all  the  symptoms  of  a  sprained 
wrist.  He  reported  to  the  doctor  at  once.  The  wrist  was  a;-rayed 
and  the  laboratory  reported  a  linear  fracture  of  one  of  the  small 
bones  in  the  wrist.  Plaster  sphnt  was  applied  and  the  employee  al- 
lowed to  go  home.  Recovery  seemed  to  progress  favorably  for  four 
days  when  suddenly  the  wrist  began  to  swell.  It  was  again  rr-rayed 
and  this  time  the  roentgenologist  noted  that  two  of  the  bones  showed 
some  change.  Both  wrists  were  then  a;-rayed  on  the  same  plate 
and  at  the  same  time.     A  comparison  of  the  two  showed  decreased 

707 


708 


INDUSTRIAL    MEDICINE    AND    SURGERY 


density  in  all  of  the  bones  of  the  right  wrist.  The  first  plate  was  then 
carefully  re-examined  and  what  had  been  considered  a  fracture  was 
found  to  be  a  small  area  of  necrosis  in  the  bone.  A  diagnosis  of 
probable  tuberculosis  of  the  wrist  was  made  and  fixation  treatment 
continued.     A  week  later  the  a:-ray  showed  definite  necrosis  of  two 


Fig.   198. — Tuberculous  wrist  joint  discovered  few  days  following  injury  to  wrist. 

of  the  bones  and  the  others  were  beginning  to  lose  their  clear  outline 
(see  Fig.  198).  In  spite  of  complete  immobilization  of  the  wrist 
and  keeping  the  patient  quiet  in  bed  the  diseased  condition  progressed 
rapidly  and  within  a  month  there  were  signs  of  fluctuation  about  the 
joint.     After  consultation  it  was  decided  that  active  operative  treat- 


.J 


Fig.   199. — Same  as  Fig.  189,  a  month  later. 

ment  was  indicated;  the  joint  was  opened  and  all  of  the  bones  curetted 
out.  Drainage  was  established  and  irrigations  of  weak  iodin  solution 
were  given.  The  wrist  was  immobilized  so  as  to  give  the  best  func- 
tional result  on  recovery.  At  the  end  of  three  months  the  wound 
had  practically  healed.     Two  months  later  this  patient  showed  the 


THE    COINCIDENCE    OF    ACCIDENTS    AND    DISEASE  709 

early  signs  of  pulmonary  tuberculosis  and  was  sent  to  a  sanitarium 
in  New  Mexico  where  he  remained  for  eight  months.  He  returned 
in  excellent  condition,  all  signs  of  the  pulmonary  trouble  having  dis- 
appeared. He  had  been  using  his  right  wrist  for  the  last  three  months 
and  to  our  surprise  had  considerable  motion.  The  x-ray  showed  no 
signs  of  the  tuberculous  bone  disease.  At  the  end  of  thirteen  months 
this  employee  was  back  at  work.  Realizing  that  it  would  be  dangerous 
for  him  to  return  to  heavy  manual  labor  we  had  stimulated  him  to 
study  along  clerical  lines  so  that  on  his  return  he  was  placed  at  clerical 
work.  A  year  later  this  wrist  showed  signs  of  swelling  and  he  com- 
plained of  some  pain.  The  x-ray  showed  no  pathologic  change  in  the 
joint  but  nevertheless  it  was  immobilized  and  he  was  given  a  three 
months'  rest  in  the  country.  The  symptoms  disappeared  and  thus 
far  no  further  trouble  has  been  noted. 

In  this  case  we  had  to  deal  with  an  accident  to  a  wrist-joint,  un- 
doubtedly the  seat  of  an  already  existing  disease.  The  fact  that  the 
employee  had  noticed  no  trouble  in  the  joint  prior  to  the  accident 
and  yet  almost  immediately  following  it  the  diseased  condition  became 
acute  caused  the  surgeon  to  decide  that  the  accident  was  responsible 
for  lighting  up  a  pre-existing  condition.  It  was  impossible  to  state 
definitely  to  what  extent  the  accident  was  responsible  for  his  dis- 
ability and  to  what  extent  the  tuberculous  condition  should  be  held 
to  blame.  On  the  strength  of  this  statement  the  management  assumed 
complete  responsibility  and  paid  this  employee  his  full  wages  during 
the  entire  length  of  his  disability,  including  the  three  months  he  was 
absent  from  work  a  year  later. 

Case  2. — V.  B.  (male — 26  years  old)  employed  as  a  gas  fitter, 
bruised  his  left  forearm  on  a  gas  pipe.  He  showed  the  injured  member 
to  his  foreman  but  objected  to  reporting  to  the  doctor  when  this  course 
was  suggested  to  him.  The  foreman,  thinking  the  condition  trivial, 
did  not  insist  upon  his  reporting.  A  week  later  he  came  to  the  doctor's 
office,  complaining  of  swelling  of  the  forearm  and  inability  to  use  the 
member.  It  was  immediately  x-rayed  and  the  radius  was  found  to 
be  thickened  throughout  its  entire  length.  The  condition  was  recog- 
nized as  one  of  an  old  osteitis  and  could  not  possibly  have  been  the 
result  of  the  slight  accident  which  he  received.  The  patient  denied 
any  pre-existing  disease  in  this  arm.  A  Wassermann  was  taken 
but  was  negative.  From  the  patient's  brother  the  name  of  the  family 
physician  in  the  country  was  obtained.  On  inquiry  by  letter,  this 
doctor  replied  that  he  had  treated  the  patient  several  years  previously 
for  a  swelling  of  the  forearm  which  he  thought  at  the  time  was  an 
osteomyelitis,  but  which  recovered  without  operative  interference. 
When  Mr.  B.  was  confronted  with  this  evidence  he  replied  that  he 
had  forgotten  about  that  illness.     He  was  told  that  he  had  better 


710  INDUSTRIAL    MEDICINE    AND    SURGERY 

return  to  work  as  the  condition  of  which  he  complained  had  existed 
for  many  years  and  had  no  connection  with  his  accident.  He 
followed  this  advice  and  made  no  claim  for  the  two  weeks'  loss  of  time. 

In  this  case  the  management  was  advised  that  the  accident  and  the 
pre-existing  condition  were  merely  coincidental  and  that  the  former 
had  not  been  sufficiently  serious  to  cause  disability.  The  author  has 
seen  three  cases  somewhat  similar  to  the  above.  Following  a  slight 
accident  there  was  noted  a  thickening  of  the  bone  in  the  injured 
members.  X-ray  showed  in  each  case  a  syphilitic  osteitis  and  in  each 
the  Wassermann  was  positive.  In  two  of  these  cases  the  condition 
completely  cleared  up  under  syphilitic  treatment.  In  none  of  them 
was  the  injury  held  in  any  way  responsible  as  the  diseased  condition 
had  undoubtedly  existed  prior  to  the  accident  and  was  not  aggravated 
by  it. 

Case  3. — T.  J.  (male — 44  years  old)  employed  as  a  packer,  was 
struck  on  the  right  thigh  by  a  heavy  box,  A  considerable  contused 
area  resulted  and  was  treated  in  the  doctor's  office  at  once.  Two 
months  later  he  reported  because  of  a  large  swelling  in  the  thigh  at 
the  point  of  injury.  A  tumor  mass  could  easily  be  palpated  and  an 
operation  was  performed.  A  tumor  about  the  size  of  a  lemon  was 
removed.  The  pathologic  report  stated  that  this  was  a  syphilitic 
gumma.  A  Wassermann  was  then  made  and  found  to  be  3  plus 
positive.     Syphilitic  treatment  was  instituted  at  once. 

In  this  case  it  was  decided  that  the  accident  had  aggravated  an 
existing  disease.  Besides  the  surgeon  had  performed  an  operation 
upon  the  patient  which  might  have  been  avoided  by  proper  syphilitic 
treatment.     Full  disability  claims  were  paid  to  this  employee. 

Syphilis  is  one  of  the  commonest  conditions  which  complicate 
accident  cases.  Careful  diagnosis  is  always  necessary  to  determine 
whether  the  accident  is  responsible  for  the  disability  or  whether 
this  pre-existing  disease  is  solely  responsible,  the  accident  merely  being 
a  coincidence. 

Case  4. — F.  H.  (male — 18  years  old)  employed  by  this  concern  for 
two  weeks  when  he  reported  to  the  doctor's  office  with  his  right  arm 
fractured  near  the  shoulder  joint.  The  history  of  the  case  was  pe- 
culiar. He  had  been  pushing  a  small  truck  through  the  aisle  when  he 
collided  with  another  small  truck.  He  felt  something  crack  in  his  arm 
but  felt  no  pain.  He  was  unable  to  raise  the  arm  after  this  accident. 
X-ray  examination  showed  a  pathological  fracture  due  to  a  bone  cyst 
which  involved  the  upper  four  inches  of  the  humerus. 

The  condition  was  carefully  explained  to  the  management  and  it 
was  felt  that,  while  there  might  not  be  any  legal  responsibility,  yet  the 
fact  that  this  boy  had  been  employed  after  a  physical  examination  and 
then  met  with  a  sHght  accident  while  at  work  resulting  in  the  fracture 


THE    COINCIDENCE    OF    ACCIDENTS    AND    DISEASE  711 

of  an  already  diseased  arm,  there  was  a  certain  amount  of  moral  re- 
sponsibility involved.  Full  wages  were  paid  during  the  entire  length 
of  his  disability.  An  operation  was  performed  in  this  case  and  a  bone 
transplant,  seven  inches  long,  taken  from  the  tibia  was  inserted.  Only 
a  shell  of  the  head  of  the  humerus  remained  after  the  bone  cyst  was 
removed  and  the  transplant  was  held  firmly  against  this  shell  by  sutur- 
ing the  soft  tissues  about  it.  It  took  six  months  for  this  case  to  recover 
sufficiently  to  return  to  light  work.  At  the  end  of  a  year  the  bony 
defect  was  completely  filled  in  and  had  practically  regained  the  normal 
contour  of  the  humerus.  Perfect  function  was  obtained  in  this  case 
(see  Figs.  173  to  176). 

During  his  stay  in  the  hospital  he  was  persuaded  to  take  up  certain 
studies  and  after  he  returned  to  hght  work  he  attended  night  school, 
learning  stenography  and  book-keeping. 
He  stayed  with  the  concern  for  a  year  after 
his  recovery  and  then  accepted  a  position 
with  a  bonding  hou^e  where  he  has  de- 
veloped into  a  successful  bond  salesman. 
This  boy  was  the  son  of  very  poor  parents 
and  was  surrounded  by  poor  environment. 
They  were  in  no  position  to  stand  the  ex- 
pense  of  a  law  suit  and  if  any  other  course  J'^J^^'^^L^Zl  XVI 
had  been  pursued  by  this  concern  the  slight  occupational  injury  had 
chances  are  that  this  boy's  future  would  rpToyer%e'sp„°Se/'  *"" 
have  been  jeopardized. 

Case  5. — D.  R.  (male — 21  years  old)  employed  one  year  as  a  ship- 
ping clerk,  was  struck  in  the  right  side  of  his  chest  near  the  spine  by  a 
box  weighing  about  25  pounds,  which  was  pitched  by  a  fellow  employee. 
He  was  immediately  sent  to  the  doctor's  office  although  not  complain- 
ing of  severe  injury.  Inspection  showed  a  small  abrased  area. 
This  was  dressed  and  he  returned  to  work.  The  next  day  he  reported 
for  a  dressing  and  was  seen  by  the  chief  surgeon.  This  man's  general 
appearance  was  not  good;  he  was  underweight,  hollow-chested  and 
rather  pale.  On  questioning  him,  he  stated  that  he  had  lost  consider- 
able weight  during  the  last  six  months  but  no  other  symptoms  were 
elicited.  A  thorough  examination  was  at  once  made  and  revealed  the 
signs  of  an  early  pulmonary  tuberculosis,  the  diagnosis  of  which  was 
proven  by  finding  tubercle  bacilh  in  the  sputum.  The  wound  was 
practically  healed  and  needed  no  further  attention.  However,  follow- 
ing the  usual  custom  of  this  concern,  the  boy  was  told  of  his  lung 
condition,  and  was  sent  home.  A  nurse  called  that  afternoon  and 
asked  his  mother  to  come  in  to  see  the  chief  surgeon.  The  next  day 
she  called  and  the  boy's  condition  was  carefully  explained  to  her.  She 
was  told  that  the  slight  accident  which  he  suffered  had  no  relation  to  • 


712  INDUSTRIAL    MEDICINE    AND    SURGERY 

the  tuberculosis,  but,  following  its  usual  procedure,  the  management 
was  willing  to  pay  this  employee's  expenses  at  a  sanatorium  until  the 
lung  condition  had  been  arrested  or  cured.  The  mother's  consent  was 
gained  and  the  patient  was  sent  to  Edward's  Sanatorium,  Naperville, 
111.  Eight  months  later  he  returned  with  the  disease  arrested.  He 
was  advised,  however,  both  at  the  sanatorium  and  at  the  office  to 
continue  his  treatment  at  home  for  two  months  longer  and  not  to 
return  to  work.  Three  weeks  later  the  management  received  notice 
from  a  lawyer  that  this  patient  had  entered  suit  for  permanent  dis- 
ability due  to  pulmonary  tuberculosis  and  Pott's  disease,  both  of 
which  were  the  direct  result  of  a  serious  accident  received  while 
in  their  employ.  After  many  diplomatic  maneuvers  the  chief  surgeon 
finally  persuaded  the  patient's  lawyer  and  doctor  to  consent  to  a  con- 
sulation  in  order  to  ascertain  whether  or  not  the  Pott's  disease  was 
present.  This  consent  was  gained  on  the  grounds  that  we  would 
consider  the  blow  from  the  box  a  contributing  factor  to  Pott's  disease 
if  the  condition  had  developed  at  or  near  the,  site  of  injury,  but  we 
would  not  consider  the  accident  in  any  way  responsible  for  the  pul- 
monary tuberculosis.  At  the  consultation  and  with  the  aid  of  the  best 
x-ray  experts  in  the  community  we  were  able  to  disprove  the  presence 
of  Pott's  disease.  Claim  for  disability  on  account  of  pulmonary 
tuberculosis  was  made,  however,  and  the  case  went  to  trial.  We  had 
no  difficulty  in  proving  that  a  pulmonary  tuberculosis  which  at  no 
time  presented  any  acute  symptoms  and  which  was  discovered  the  day 
following  the  accident  was  never  caused  by,  nor  aggravated,  by  this 
injury.  The  court  further  observed  that  the  concern  had  been  very 
generous  in  its  treatment  of  D.  R.  by  offering  him  the  opportunity  of 
being  cured  of  a  tuberculous  condition  for  which  they  were  not 
responsible. 

Case  6. — H.  B.  (male — 26  years  old)  reported  to  the  doctor's 
office  with  his  right  heel  severly  bruised  as  a  result  of  being  struck  by 
a  truck.  This  man's  general  appearance  was  not  good  and  a  thorough 
examination  was  immediately  made.  Pulmonary  tuberculosis  in 
the  second  stage  was  diagnosed  and  was  confirmed  by  numerous 
tubercle  bacilh  in  the  sputum.  Within  a  week  he  had  recovered  from 
the  injury  to  his  heel.  This  man  was  Ukewise  given  free  sanitorium 
treatment  because  of  his  lung  condition,  although  the  concern  was  in 
no  way  responsible  for  it.  Four  months  later  we  were  notified  by  the 
sanitorium 's  physician  that  this  patient's  right  foot  and  ankle  were 
badly  swollen.  He  was  sent  back  to  the  city  and  placed  in  a  hospital. 
X-ray  examination  showed  a  condition  of  tuberculosis  of  the  right 
ankle-joint.  The  foot,  ankle  and  leg  were  placed  in  a  plaster  cast 
and  the  patient  was  returned  to  the  sanitorium  where  he  was  kept 
completely  at  rest.     The  cast  was  changed  every  three  weeks.     He 


THE    COINCIDENCE    OF    ACCIDENTS    AND    DISEASE  713 

was  kept  in  the  sanitorium  for  fifteen  months  at  the  end  of  which 
time  the  pulmonary  condition  was  arrested  and  signs  of  the  disease 
■  in  the  ankle-joint  had  disappeared. 

The  surgeon  held  that  the  management  was  responsible  for  the 
tuberculous  condition  in  the  extremity  because  a  severe  injury  had 
occurred  to  the  heel  and  ankle  of  a  man  already  suffering  from 
pulmonary  tuberculosis  and,  as  a  result  of  the  injury  the  resistance 
of  the  part  was  lowered  and  made  possible  the  extension  of  the  disease. 
An  insurance  company  might  have  fought  this  case  and  brought 
up  legal  barriers  to  any  claim  of  disability.  However,  there  was 
undoubtedly  a  moral  responsibility  involved  and,  without  any  claims 
for  disability  on  the  part  of  the  patient,  the  concern  voluntarily 
assumed  this  obligation. 

Case  7. — This  was  another  case  of  tuberculosis  of  the  bone.  This 
patient  was  struck  by  a  hea-^y  plank  just  above  the  right  knee.  On 
examination  a  severe  contusion  was  found.  There  were  scars  of  a 
previous  diseased  condition  about  the  hip  and  over  the  entire  length 
of  the  right  femur.  The  history  of  the  case  showed  that  this  patient 
had  suffered  from  tuberculosis  of  the  hip  and  the  femur  during  his 
boyhood,  some  twenty  years  previously.  Four  weeks  after  the  injury 
the  patient  developed  considerable  swelling  in  the  lower  thigh,  pain 
and  tenderness  and  a  low  grade  temperature.  X-ray  showed  necrosis 
involving  the  greater  portion  of  the  lower  third  of  the  thigh.  He 
was  operated  upon  and  three  weeks  later  a  second  operation  was 
necessary.  Almost  a  year  elapsed  before  this  patient  recovered. 
At  no  time  were  the  symptoms  acute  but  were  those  of  a  chronic 
osteomyelitis,  evidently  of  a  tuberculous  origin.  The  accident  was 
held  responsible  although  undoubtedly  the  pre-existing  disease  was 
the  chief  contributing  factor.     Full  compensation  was  paid  this  man. 

Case  8. — Miss  B — 28  years  old — a  three  weeks'  employee,  fell 
from  the  second  step  of  a  stepladder  striking  on  her  buttocks.  Ex- 
amination failed  to  reveal  any  sign  of  injury  although  the  patient  was 
very  hysterical  and  nervous  from  the  moment  of  the  accident.  A 
vaginal  examination  was  not  made.  Two  weeks  later  this  young  lady 
entered  claim  for  disability  on  account  of  a  retrodisplacement  of  the 
uterus  and  a  dislocated  coccyx.  She  had  consulted  a  lady  physician 
who  had  examined  her  vaginally  and  made  this  diagnosis.  The  patient 
was  able  to  be  up  and  around  but  had  not  returned  to  work.  At  first 
both  the  patient  and  her  doctor  refused  to  allow  the  company  surgeon 
to  make  an  examination.  Finally  the  surgeon  called  on  the  family 
physician  and  explained  to  her  that  if  these  conditions  were  present 
the  concern  would  pay  full  compensation.  Since  she  was  so  positive 
of  her  findings  it  was  suggested  that  she  call  in  a  consultant  and  the 
surgeon,  would  call  in  a  consultant  and  the  four  would  make  a  complete 


714  INDUSTRIAL    MEDICINE    AND    SURGERY 

examination  of  the  case  at  the  same  time  and  decide  what  pathologic 
condition,  if  any,  existed  and  to  what  extent  the  accident  was  respon- 
sible. This  plan  was  carried  out  and  neither  of  the  two  consultants 
nor  the  company  surgeon  were  able  to  find  any  signs  of  a  retroversion 
or  of  a  dislocated  coccyx.  It  took  two  weeks,  however,  to  persuade 
the  patient  that  she  was  only  suffering  from  the  mental  suggestion 
of  her  doctor  and  no  real  condition.  After  she  returned  to  work  she 
was  given  her  full  wages  for  the  four  weeks  lost  time  as  the  accident 
had  made  this  comedy  of  errors  possible. 

The  author  has  been  able  to  stop  many  claims  for  compensation 
by  this  plan  of  arbitration  by  two  consultants,  chosen  one  by  the 
family  physician  and  one  by  the  company  surgeon.  Usually  when 
four  doctors  thus  get  together  each  feels  it  a  matter  of  pride  to  make 
a  correct  diagnosis  without  at  the  time  considering  its  bearing  on 
compensation.  If  such  a  policy  were'  universally  adopted  many 
damage  suits  could  be  equitably  settled  by  the  doctors  without  the 
expense  and  wrangling  injected  into  the  case  by  placing  it  in  the 
hands  of  lawyers. 

Case  9. — Medical  cases,  as  well  as  surgical,  present  many  of  the 
above  difficulties.  P.  G.  (male — 48  years  old)  a  printer,  working  for 
the  concern  some  six  years,  reported  to  the  doctor's  office  because  of 
dizziness,  shortness  of  breath  and  general  weakness.  The  examination 
showed  a  blood-pressure  of  180  degrees  and  albumen,  hyalin  and 
granular  casts,  in  the  urine.  All  reflexes  were  reported  as  normal 
at  this  examination.  A  diagnosis  of  chronic  interstitial  nephritis 
was  made.  This  man  was  granted  a  six  months'  leave  of  absence  on 
full  pay.  At  the  end  of  that  time  he  was  dropped  from  the  pay  roll. 
He  belonged  to  the  Printers  Union  and  was  entitled  to  a  small  weekly 
benefit  for  quite  a  period  from  them.  A  short  time  after  this  the 
management  was  notified  by  the  wife  that  her  husband  was  in  the 
hospital  under  treatment  for  lead  poisoning  and  that  his  occupation 
as  a  printer  was  responsible  for  the  condition.  She  entered  claims 
for  disability  and  threatened  suit  unless  these  were  paid.  The  chief 
surgeon  arranged  for  a  consultation  with  the  doctors  in  charge  of  this 
case  at  the  hospital.  The  history,  which  his  doctors  had  obtained 
stated  that  the  patient  had  been  suffering  paroxysms  of  abdominal 
pain  for  the  last  four  months.  He  had  grown  progressively  weaker  and 
had  developed  paresis  of  his  left  leg.  There  was  a  mild  foot-drop 
on  the  left  side.  Severe  constipation  was  present  and  the  urine  ex- 
amination showed  a  low  grade  nephritis.  The  laboratory  report 
showed  basophilic  degeneration  of  the  red  cells,  with  a  marked  second- 
ary anemia.     The  Wassermann  test  was  negative. 

The  above  findings,  coupled  with  the  fact  that  this  man  had  been  a 
printer,  and  exposed  to  lead  during  the  last  six  years  had  caused  his 


THE    COINCIDENCE    OF    ACCIDENTS    AND    DISEASE  715 

physicians  to  make  the  diagnosis  of  lead  poisoning  and  in  their  judg- 
ment they  were  honestly  justified  in  advising  the  man's  wife  that  his 
employment  was  responsible  for  the  condition. 

The  chief  surgeon  proceeded  to  make  a  thorough  examination  from 
head  to  foot.  He  found  all  of  the  conditions  described  above,  but 
in  addition  a  decided  ankle  clonus  was  present;  the  Babinski  sign 
was  positive;  and  a  typical  saddle  anesthesia  was  discovered.  After 
having  demonstrated  these  signs  to  his  physicians  consent  was  obtained 
to  make  a  spinal  puncture  and  have  a  Wassermann  test  made  on  the 
spinal  fluid.  This  was  done  and  half  of  the  fluid  removed  was  sent 
to  the  laboratory  at  this  hospital  and  half  of  it  was  taken  to  one  of  the 
expert  laboratory  men  of  the  city.  The  report  from  both  showed  a 
very  decided  Wassermann  reaction  in  the  spinal  fluid.  A  diagnosis 
of  syphilitic  spinal  meningitis  was  made  and  was  agreed  to  by  the 
patient's  physicians.  The  patient  died  a  month  later  but  before 
his  death  he  confessed  to  his  wife  that  he  had  contracted  syphilis 
before  they  were  married,  although  in  all  the  histories  taken  of  the 
case  he  had  denied  this  infection.  It  was  not  until  this  confession 
was  made  that  the  wife  was  satisfied  that  his  occupation  was  not 
responsible. 

This  case  very  aptly  illustrates  this  problem  of  coincidental  diseases. 
The  doctor  on  the  staff  of  this  industry,  who  examined  the  patient 
first,  failed  to  discover  the  syphilitic  condition  because  after  a  routine 
examination  he  was  able  to  make  a  diagnosis,  namely,  chronic  nephritis. 
Later  the  physicians  who  attended  this  patient  felt  that  they  had 
worked  up  the  case  very  thoroughly  and  found  a  sufficient  number  of 
symptoms,  combined  with  the  history  of  the  employment  of  the  patient 
as  a  printer  to  enable  them  to  make  a  diagnosis  of  lead  poisoning. 
They  were  very  honest  and  efficient  physicians.  However,  before 
any  doctor  makes  a  diagnosis  or  a  statement  which  involves  claims 
for  large  damages  against  any  industry  he  should  be  mighty  sure  of 
his  grounds.  These  coincidental  diseases  which  are  usually  the  specific 
causes  of  the  disability  can  only  be  discovered  by  going  over  every 
case  with  a    "fine  tooth  comb." 

Strained  Backs. — Employees  complaining  of  strained  backs  fol- 
lowing overlifting,  sudden  twisting  of  the  body,  falls  and  like  condi- 
tions furnish  the  best  examples  of  slight  accidents  coincidental  with 
a  diseased  condition.  These  cases  are  often  the  most  difficult  to 
determine  the  exact  responsibility,  and  when  it  is  decided  that  disease 
is  the  underlying  cause  it  requires  the  most  convincing  arguments  to  • 
persuade  the  employee  that  it  is  not  the  result  of  some  strain. 

The  histories  of  these  cases  are  quite  similar.  An  employee  reports 
to  the  doctor's  office  complaining  of  severe  pain  in  his  back.  He  is 
often  slightly  bent  forward  and  both  hands  are  pressed  into  the  small 


716  INDUSTRIAL    MEDICINE    AND    SURGERY 

of  his  back.  While  talking  he  will  catch  his  breath  due  to  a  sudden 
paroxysm  of  pain  in  the  back.  He  states  that  when  he  left  home  that 
morning  he  was  perfectly  well  but  after  working  awhile  he  tried  to 
lift  a  heavy  box,  or  some  other  object,  and  must  have  strained  his 
back,  for  a  sudden  pain  struck  him  and  he  couldn't  straighten  up.  Or 
he  will  tell  of  twisting  his  body  while  exerting  himself  and  the  strain 
of  the  back  resulted. 

It  is  pecuHarly  characteristic  of  these  cases  that  if  they  are  consid- 
ered as  injuries  and,  therefore,  compensable,  they  will  have  a  prolonged 
period  of  disability.  Whereas  if  the  true  nature  of  the  condition  is 
discovered  at  once  and  they  are  treated  as  diseases  the  period  of 
disability  is  greatly  shortened. 

A  thorough  physical  examination  should  be  made  at  once  of  all 
such  back  cases.  A  special  search  should  be  made  for  foci  of  infec- 
tions in  the  teeth,  tonsils,  prostate,  and  about  the  nails.  The  urine 
should  always  be  examined.  Signs  of  rheumatism  in  other  parts  of 
the  body  should  be  sought.  An  x-ray  examination  will  occasionally 
show  a  chronic  arthritis  about  the  spinal  vertebrae,  especially  at  the 
sacro-iliac  joints.  Careful  questioning  will  often  bring  out  the  fact 
that  similar  attacks  have  occurred. 

The  nature  of  the  alleged  accident  should  likewise  be  thoroughly 
investigated.  Was  the  overHfting  or  twisting  of  such  a  nature  as  to 
result  in  a  strain  of  the  muscles  of  the  back  or  to  actually  tear  some 
of  the  intervertebral  ligaments?  When  an  accident  is  responsible 
for  the  back  condition  usually  it  causes  a  direct  injury  to  the  soft  parts 
over  the  back,  as  a  contusion  from  a  fall,  or  it  is  of  a  sufficiently  serious 
nature  as  to  cause  a  strain  to  anyone  subjected  to  a  similar  accident. 

By  weighing  the  evidence  thus  collected  the  surgeon  can  usually 
decide  whether  the  condition  is  a  lumbago,  myositis,  neuritis  or  typical 
rheumatism  due  to  conditions  already  existing  in  the  patient's  body; 
whether  the  accident  was  the  sole  cause  of  the  trouble;  or  whether 
there  was  an  existing  predisposition  and  the  alleged  accident  aggra- 
vated the  condition.  In  the  majority  of  instances  these  cases  will  be 
found  to  be  due  to  disease  and  the  slight  strain  is  in  no  way  responsible 
except  as  ''an  alarm  clock  which  suddenly  awakens  the  dormant 
condition. " 

All  of  these  facts  must  be  patiently  and  tactfully  explained  to  the 
employee.  He  must  then  be  persuaded  to  have  the  focus  of  infection 
removed,  or  the.  diseased  condition  treated. 

I  have  seen  many  recurring  attacks  of  so-called  strained  backs  in 
employees  which  promptly  yielded  to  tight  strapping  with  adhesive 
plaster  and  a  few  days  rest.  After  these  employees  submitted  to 
dental  work  or  to  the  removal  of  diseased  tonsils  the  attacks  prac- 
tically always  ceased  to  recur. 


THE    COINCIDENCE    OF    ACCIDENTS    AND    DISEASE  717 

t 

During  one  year  156  employees  reported  to  the  doctor's  office  on 
account  of  strained  backs  due  to  alleged  accidents.  In  one  of  these 
there  was  a  definitely  bruised  back  and  the  general  examination  was 
negative.  In  twenty  the  nature  of  the  extreme  effort,  or  exertion  or 
fall  was  such  as  to  justify  straining  of  the  back  and  they  were  con- 
sidered compensable  cases.  In  only  eight  of  these  were  mild  foci  of 
infection  found,  the  remainder  being  apparently  free  of  infection. 

The  remainder  were  diagnosed  as  follows  and  gave  the  following 
findings  of  preexisting  infections: 

(1)  Lumbago 82 

(a)  Pyorrhea 13 

(6)  Abscessed  teeth 32 

(c)  Extremely  bad  teeth 3 

(d)  Diseased  tonsils  and  teeth 10 

(e)  Diseased  tonsils 10 

(/)  Acutely  inflamed  tonsils 1 

(g)  Acute  "colds" '. 8 

(h)  Acute  gonorrhea 1 

(i)  Chronic  gonorrhea 2 

(/)  Nephritis 1 

(2)  Strained  (?)  back  with  other  conditions 8 

(a)  Flat  feet 6 

(&)  Diseased  tonsils 2 

(3)  Myositis 3 

(a)  Bad  teeth 1 

(6)  Diseased  tonsils  and  teeth 1 

(c)  Influenza 1 

(4)  Neuritis  and  myositis 4 

(a)  Bad  teeth 1 

(b)  Diseased  tonsils 2 

(5)  Rheumatism 13 

(a)  Diseased  tonsils 4 

(&)  Bad  teeth  and  tonsUs 2 

(c)  Pyorrhea 1 

(6)  Sacro-iliac  arthritis 2 

(a)  Bad  teeth 1 

(b)  Diseased  tonsils 1 

(7)  Sciatica 3 

(a)  Diseased  tonsils 1 

(b)  Flat  feet 2 

(8)  Miscellaneous 20 

(a)  Slight  strain 10 

(b)  Rheumatic  tendency 2 

(c)  Not  diagnosed,  history  obscure,  no  findings,  lost  no  time 8 

These  156  cases  lost  511%  days  from  work.  Every  one  of  the 
cases  with  teeth  trouble  had  dental  work  performed  under  the  super- 
vision of  the  plant  dentist.  Twenty  of  these  employees  submitted 
to  removal  of  the  diseased  tonsils.  The  flat-foot  cases  had  their  arches 
strapped  and  suitable  shoes  and  arch  supports  were  secured. 


718  INDUSTRIAL    MEDICINE    AND    SURGERY 

These  figures  prove  the  value  of  thoroughly  searching  for  the  cause 
in  all  cases  of  so-called  strained  back.  Otherwise  much  loss  of  time 
from  work  will  ensue  and  many  of  these  employees  will  become  the 
typical  "back-neurotic"  requiring  many  weeks  of  compensation. 

Many  other  cases  could  be  quoted,  illustrating  the  problems 
presented  when  accident  or  disease  is  comphcated  by  some  coinci- 
dental pathologic  condition.  No  definite  rules  can  be  laid  down  for 
determining  the  responsibility  for  disability  resulting  in  such  cases.  It 
is  usually  impossible  for  any  physician  to  honestly  divide  this  responsi- 


FiG.  201. — A  lymph-edema  of  the  hand  and  arm  following  a  slight  scratch,  from  a 
pin,  while  at  work.  At  first  a  mild  infection  developed  which  was  incised  and  drained. 
The  above  condition  followed  and  persisted  for  over  a  year.  Under  hot  dressings  it 
would  disappear  to  recur  again  in  a  week  or  two.  A  month  after  the  accident  a  Was- 
sermann  test  was  made  and  was  positive.  AntisyphiHtic  treatment  was  given  and  in 
four  months  all  Wassermanns  were  negative.  The  condition  resisted  every  line  of 
treatment  and  finally  seemed  to  disappear  spontaneously.  Undoubtedly  a  coincidental 
condition  existed  in  this  case,  but  following  an  accident  as  it  did  the  concern  was  held 
responsible. 

bihty,  assigning  a  certain  percentage  to  the  accident  and  a  certain 
percentage  to  the  associated  condition.  Each  individual  case  must  be 
carefully  analyzed  and  these  questions  must  be  settled  by  considering 
both  the  moral  and  legal  aspects  involved. 

Industrial  compensation  commissions  will  find  these  questions,  as 
well  as  other  medical  problems,  can  best  be  solved  by  disinterested 
medical  consultants  rather  than  by  lawyers.  Therefore,  every  such 
commission  should  have  its  staff,  consisting  of  the  best  medical  and 
surgical  talent,  in  order  that  the  greatest  justice  may  be  done  both  the 
employer  and  the  employee. 


CHAPTER  XLIV 
OTHER  TRAUMATISMS  WITH  MEDICOLEGAL  ASPECTS 

With  the  tendency  of  large  corporations  to  depend  more  and  more 
on  the  decisions  and  statements  of  their  surgeons  as  to  the  compensable 
nature  of  various  accident  cases  it  is  very  essential  for  every  surgeon  in 
industry  to  develop  a  medicolegal  sense.  In  fact  such  a  sense,  if 
acquired  by  all  physicians,  would  undoubtedly  reduce  the  claims  for 
compensation  materially,  for  the  exaggerated  statements  of  doctors  to 
their  patients  are  the  commonest  causes  for  exaggerated  claims. 

Many  state  compensation  laws  permit  of  the  settlement  of  claims 
between  the  employer  and  employee  without  a  hearing  before  the  boards, 
a  receipt  of  the  amounts  of  compensation  paid  being  all  that  is  required. 
Only  disputed  claims,  therefore,  come  before  the  industrial  board.  In 
such  states  the  medical  profession  and  especially  surgeons  connected 
with  industry,  or  with  insurance  companies,  have  a  great  responsi- 
bihty  placed  in  their  hands.  They  at  once  become  the  judge  and  jury 
in  many  injury  cases  and  on  their  honest  decisions  depend  the  render- 
ing of  right  and  justice  to  both  employer  and  employee. 

There  is  a  more  or  less  prevalent  impression  that  the  family 
physician  favors  the  side  of  the  employee,  and  the  surgeon  in  industry 
favors  the  employer's  side,  while  the  insurance  doctor  is  prejudiced  in 
favor  of  the  insurance  company. 

Unfortunately  this  was  too  often  the  case  in  old  days  when  our 
personal  injury  suits  were  settled  in  courts.  Such  prejudices  are 
becoming  less  prevalent  in  these  days  of  employees  compensation. 

If  every  surgeon  will  adopt  a  pohcy  of  absolute  honesty,  will  become 
a  just  judge,  and  will  render  his  decisions  after  a  careful  consideration 
of  the  medical,  moral  and  legal  aspects  of  each  case,  and  if  employers 
will  then  make  just  settlements  in  all  cases  where  they  are  either 
morally  or  legally  responsible,  there  will  be  a  lessened  tendency  for 
employees  to  make  exaggerated  claims  of  disabihty;  in  the  long 
run  they  will  receive  greater  compensation  than  by  the  old  system  of 
court  trials,  interested  expert  witnesses,  and  legal  counsel. 

Certain  traumatic  conditions  will  always  arise,  however,  which  wiU 
cause  disputed  claims.  The  growing  tendency  of  compensation  com- 
missions to  employ  their  own  medical  staffs  of  disinterested  surgeons, 
who  can  render  just  decisions  in  these  cases,  is  reducing  such  claims 
materially  and  is  resulting  in  greater  justice  to  both  sides.     Undoubt- 

719 


720  INDUSTRIAL    MEDICINE    AND    SURGERY 

edly  the  enactment  of  health  insurance  laws,  enabling  working  men 
to  receive  compensation  for  conditions  which  are  not  considered 
compensable  accident  cases  would  reduce  these  disputed  claims  to 
a  minimum. 

Many  authorities  have  argued  that  employees'  compensation  and 
workmen's  health  insurance  would  at  once  mean  a  greatly  increased 
number  of  neurotics  and  mahngers.  It  has  been  my  observation  that 
since  quick  and  more  liberal  settlement  of  employees  claims  for 
disability  have  been  adopted  the  number  of  cases  of  traumatic  neuroses 
and  malingering  have  decreased.  For  nine  years  I  have  had  the 
privilege  of  serving  a  concern  in  which  all  five  year  employees  received 
full  wages  during  the  entire  period  of  their  disabihty  on  account  of 
sickness,  and  all  employees  of  less  than  five  years  service  could  join  the 
benefit  association  and  receive  two-thirds  of  their  wages  while  absent 
on  account  of  sickness.  All  accident  cases  received  full  wages  during 
their  entire  disability.  Such  a  Hberal  policy  has  given  ample  oppor- 
tunity for  studying  the  effect  on  imaginary  conditions  and  on 
mahngering. 

In  the  case  of  sickness  there  has  been  a  greater  tendency  to  prolong 
disability  by  claiming  neurotic  or  imaginary  conditions  among  the 
employees  receiving  just  two-thirds  of  their  wages  than  among  those 
receiving  full  wages.  During  the  entire  time  I  have  not  seen  more 
than  ten  cases  of  downright  mahngering  of  disease  among  this  entire 
group  of  employees. 

Many  cases  of  traumatic  neuroses  and  a  few  genuine  fakirs  have 
developed  among  the  injured  employees,  but  a  less  number  than  I 
have  seen  among  the  employees  of  other  concerns  which  depended  upon 
insurance  companies  to  settle  their  claims. 

Moorhead's  experience  adds  weight  to  my  belief  that  proper  com- 
pensation for  either  accident  or  disease  will  reduce  the  number  of 
exaggerated  and  false  claims.  He  says,  "since  the  Workmen's  Com- 
pensation Law  went  into  effect  in  New  York  State,  (July  1,  1914)  I 
have  been  impressed  by  the  freedom  from  exaggerated  claims,  and 
ascribe  this  to  the  fixed  payment  rates  for  definite  injuries  and  to  the 
non-interference  of  a  certain  type  of  physician  and  lawyer.  During 
the  first  twenty-six  months  of  the  operation  of  this  law  many  thousands 
of  employees  were  more  or  less  injured  in  the  various  activities  of  the 
railways  with  which  I  am  connected.  Of  this  number,  over  90  per 
cent,  required  one  treatment  only,  and  thus  the  very  great  proportion 
might  have  prolonged  disability  by  asserting  subjective  symptoms  if 
the  proper  motives  existed.  Of  the  more  seriously  hurt,  comparatively 
few  exaggerated  to  any  great  extent,  and  I  recall  but  few  whom  we 
regarded  as  out-and-out  fakirs.  I  know  of  but  few  cases  in  which 
marked  traumasthenic  symptoms  developed." 


OTHER    TRAUMATISMS    WITH    MEDICOLEGAL    ASPECTS         721 

The  tendency  of  certain  unscrupulous  physicians  and  lawyers  to 
abet  injured  persons  in  their  exaggerated  claims  for  damage  during  the 
old  days  of  personal  injury  suits  has  resulted  in  a  mass  of  "court- 
room pathology"  which  clogs  the  machinery  of  justice  in  our  state 
industrial  commissions  charged  with  employees'  compensation.  Such 
terms  as  ''railway  spine,"  traumatic  hysteria,  and  even  many  of  our 
so-called  traumatic  hernia  owe  their  origin  and  basis  for  frequent 
claims  to  many  court  proceedings.  Injured  employees  in  the  past 
were  not  so  much  to  blame  for  malingering  or  for  developing  traumas- 
thenic  symptoms  as  were  these  outside  forces — the  self-seeking  lawyer 
and  the  physician  who  so  often  unwittingly  or  otherwise  played  into 
his  hands. 

In  these  days  of  social  democracy,  when  the  surgeon  in  industry 
is  playing  so  important  a  part  in  securing  better  relations  between 
industry  and  labor,  it  behooves  all  of  us  to  strive  to  our  utmost  to  wipe 
out  this  blot  on  our  professional  history  and  in  the  future  render  our 
medical  opinions  to  both  the  injured  employee  and  his  employer  solely 
with  the  view  of  seeing  justice  done  to  both. 

TRAUMATIC  NEUROSES 

"Traumatic  neurosis"  (Oppenheim),  "traumasthenia"  (Moor- 
head),  "nervous  shock,"  " hysteroneurasthenia "  and  similar  terms 
have  been  appHed  to  certain,  definite  subjective  manifestations  which 
often  appear  following  trauma. 

These  conditions  form  the  most  frequent  basis  for  exaggerated 
claims  for  accident  compensation.  They  complicate  almost  every 
known  type  of  injury  but  more  frequently  occur  with  the  less  serious 
than  with  the  very  serious  injuries.  An  extremely  dangerous  accident 
which  might  have  killed  the  patient  but  which  only  resulted  in  mod- 
erate injury  furnishes  a  common  incentive  for  these  traumasthenias. 

The  injury  sustained  is  usually  of  such  a  nature  as  to  justify  only 
a  short  partial  disability  and  the  neurosis  becomes  the  real  cause  for 
prolonged  disability  and  even  for  claims  for  permanent  disability. 

In  the  past  many  of  these  conditions  were  regarded  by  excellent 
authorities  as  real  neural  injuries  and  were  given  such  names  as  "spinal 
concussion,"  "railroad  spine"  (supposed  to  be  most  often  due  to 
railroad  injuries),  "railroad  brain"  and  similar  terms.  These  neural 
injuries  were  described  as  "molecular  changes"  sunilar  to  those  which 
are  supposed  to  occur  in  concussion  of  the  brain. 

Of  recent  years  there  has  been  a  decided  tendency  to  doubt  the 
existence  of  any  real  neuroses,  some  claiming  that  the  condition  is 
only  assumed  or  shammed  for  a  definite  reason.  Many  of  the  cases  of 
so-called  "shell  shock,"  occurring  in  soldiers  who  have  never  been  near 

46 


722  INDUSTRIAL   MEDICINE    AND    SURGERY 

the  front,  have  strengthened  this  behef  in  some  observers,  while  others 
feel  that  "shell  shock  has  proven  the  reality  of  such  neuroses." 

There  are  all  types  and  degrees  of  these  peculiar  psychological 
states,  following  fear,  fright,  mild  injury  or  severe  injury,  and  mani- 
fested either  by  pure  faking  or  malingering;  a  mild  nervousness;  real 
neurasthenia;  a  combination  of  self  hypnotism,  giving  a  mild  hysteria 
with  a  certain  amount  of  malingering;  a  real  hysteria;  or  neurasthenia 
associated  with  hysteria. 

Excellent  contributions  to  medical  literature  have  been  given  on 
this  subject  of  neuroses  by  Oppenheim,  Mott,  Bailey,  Moorhead, 
Freud,  Janet,  Strumpell  and  many  others.  It  is  not  my  purpose  to 
enter  into  an  elaborate  description  of  these  various  states  for  to  do  so 
would  mean  a  repetition  of  much  that  has  been  written.  I  prefer  to 
express  my  private  opinions  and  impressions  concerning  traumatic 
neuroses  even  though  such  an  expression  may  not  be  couched  in  the 
classical   terminology   of  the  psychologist  or  the  neuropsychiatrist. 

These  traumatic  mental  states  can  be  divided  into  (1)  true  neurosis; 
(2)  a  combination  of  neurosis  and  faking;  (3)  true  faking.  Some 
would  say  that  the  cause  of  the  last  named  condition  is  simply  "a 
born  liar, "  but  this  is  hardly  correct.  A  careful  analysis  of  the  fakir 
will  reveal  some  abnormal  or  perverted  mental  state  which  places  him 
likewise  in  the  neuroses  group. 

The  etiologic  factors  in  traumatic  neuroses  can  be  divided  into 
(a)  predisposing,  and  (5)  exciting.     The  predisposing  causes  are: 

1.  Moral  Instability. — In  my  opinion  this  is  the  underlying  cause 
of  all  these  conditions  and  without  it  the  other  predisposing  causes 
would  cease  to  exist. 

One  psychologist  has  said  that  for  a  child  of  three  to  lie  is  normal, 
for  a  child  of  six  to  lie  is  not  serious,  but  for  a  child  of  twelve  to  lie  is 
tragic.  To  lie  does  not  imply  the  spoken  lie,  but  includes  acting  lies 
and  is  manifested  in  many  forms  such  as  cheating,  feigning,  etc.  This 
trait  often  becomes  such  a  definite  part  in  the  mental  emotions  that 
without  volition  the  feigning,  or  other  form  of  falsifying,  occurs.  This 
tendency  may  lie  dormant  for  years  and  then  when  the  subtle  tempta- 
tion (predisposing  causes)  presents  itself  the  feigning  consciously  or 
otherwise  manifests  itself. 

I  have  seen  a  child  of  three  complain  of  headache  or  a  sick  stom- 
ach, or  just  sickness  in  order  to  escape  punishment  for  some  wrongful 
act.  I  have  seen  a  child  of  six  who  has  disobeyed  his  parent  and  who 
is  fearful  of  the  impending  punishment  turn  pale,  develop  a  rapid, 
irregular  pulse,  complain  of  nausea  and  actually  voixiit  and  become 
sufficiently  sick  as  to  require  the  attention  of  a  physician.  These 
children  represent  many  varied  types  of  neuroses  and  every  phy- 
sician has  seen  such  cases.     Usually  we  ascribe  them  to  a  "spoiled 


OTHER   TRAUMATISMS   WITH   MEDICOLEGAL   ASPECTS        723 

child."  The  mental  sjtimuli  necessary  to  bring  on  these  neuroses  in 
children  take  many  forms  such  as  fear,  desire  for  personal  gain,  op- 
position, revenge,  etc. 

Analogous  conditions  are  common  in  adults.  A  man  is  late  to 
work  and  he  frames  up  an  excuse  of  sickness;  he  may  even  go  to  tho 
toilet  several  times  feigning  a  diarrhea.  Or  in  order  to  forestall  censure; 
for  his  tardiness  he  will  limp  when  reporting  to  his  foreman  and  com- 
plain of  rheumatism.  Another  man  will  fall  behind  in  his  work; 
fearing  censure  he  semiconsciously  constructs  his  excuses  and  usually 
these  take  the  form  of  some  bodily  ailment.  Thinking  of  this  con- 
dition causes  it  to  develop  subjectively  and  soon  he  is  forced  to  lay 
off  with  true  neurasthenic  symptoms. 

A  patient  of  excellent  character  became  greatly  depressed  over 
his  failing  business.  He  sought  financial  help  from  his  father  but 
it  was  refused.  He  then  became  very  sick  with  stomach  trouble, 
vomited  frequently,  lost  weight,  developed  an  anemia  and  his 
doctor  feared  cancer  of  the  stomach,  and  let  the  patient  know  of  the 
fear. 

On  account  of  his  illness  his  father  was  finally  forced  to  advance 
some  money  in  order  to  save  the  business.  Immediately  the  patient 
improved  and  was  well  within  two  weeks. 

There  are  many  recorded  cases  of  women  who  have  developed 
the  worst  types  of  neurasthenia,  hysteria,  and  even  of  faking  in  order 
to  gain  some  desired  end  such  as,  a  trip  to  California,  or  to  regain 
the  affections  of  a  husband,  or  to  revenge  some  wrong. 

All  of  these  are  examples  of  an  unstable  moral  tone  whether  they 
occur  in  the  child  of  three  or  in  the  adult  of  thirty-three.  This  failure 
to  develop  a  proper  moral  balance  will  often  light  up  an  emotional 
state  seeking  interpretation  in  some  form  of  neurosis. 

Foster  Kennedy  in  his  contribution^  entitled  ''The  Nature  of  Nerv- 
ousness in  Soldiers"  demonstrates  most  clearly  that  the  loss  of  "  morale ' ' 
in  a  soldier  is  the  basis  of  his  neurosis.  He  says,  "  What  is  this  thing  we 
call  morale  ?  Is  it  not  the  expression  in  each  soldier  of  his  herd  instinct , 
of  his  willingness  to  sacrifice  himself  for  the  benefit  of  his  kind,  and  for  the 
ideals  held  in  common  by  his  countrymen  and  himself?  It  is  a 
loyalty  to  his  mates,  to  his  officers,  to  his  regiment,  to  his  nation,  and, 
in  the  last  instance,  to  the  ideals  of  life  for  which  his  nation  stands, 
and  it  is  measured  by  his  conscious  willingness  to  suffer,  his  capacity 
for  sacrifice  in  the  common  good.  It  is  a  quality  born  of  the  tribe, 
a  product  of  gregariousness  and  so  held  socially  in  good  repute.  It  is 
constantly  expressed  in  thought;  it  is  a  real  component  of  the  soldier's 
conscious  intellectual  life.  The  shrinking  from  loss  and  the  fear  of 
death  on  the  other  hand  are  but  rarely  scrutinized  in  their  reafities; 
iJour.  Am.  Med.  Assoc,  Vol.  71,  No.  1. 


724  INDUSTRIAL   MEDICINE    AND    SURGERY 

they  are  antisocial  in  trend  and  so  are  cast  down,  by  good  citizens, 
into  the  Umbo  of  subconsciousness. 

"Perhaps  I  seem  to  you  to  have  been  wandering  from  my  subject  by 
these  considerations;  but  for  some  months  past  I  have  been  trying  to 
discover  something  of  the  dynamic  influences  in  our  men,  and  I  feel 
that  a  clue  to  the  genesis  of  the  neuroses  is  to  be  found  in  the 
antagonism  on  the  one  hand  of  the  conscious  emotions  of  loyalty  and 
morale  with  their  concomitant  urge  to  self-sacrifice,  and,  on  the 
other  hand,  the  more  or  less  satisfactorily  repressed  instincts  for  the 
conservation  of  individual  life." 

This  lack  of  morale,  the  loss  of  his  high  ideals,  a  lack  of  conscience 
enables  the  soldier  who  fears  the  fight  to  unconsciously  develop  a 
neurosis;  or  the  soldier  who  longs  for  escape  from  the  horrors  and 
abominations  of  the  trenches  to  develop  "shell  shock"  without  any 
visible  signs  of  injury.  All  authorities  report  that  the  seriously 
wounded  seldom  if  ever  develop  neuroses.  Why  should  they?  Their 
wounds  give  them  the  honorable  means  of  escape  from  these  horrors. 
They  have  been  true  to  their  ideals,  have  maintained  their  morale, 
and  now  can  rest  and  receive  their  reward. 

A  similar  condition  exists  among  employees.  If  every  effort  is 
made  to  keep  their  morale  at  a  high  point;  if  fatigue,  worry  and 
unfairness  is  reduced  to  a  minimum;  and  if  liberal  and  square  dealing 
results  in  adequate  rewards  when  injuries  are  received,  the  number 
of  cases  of  neuroses  will  be  reduced. 

Thus  the  lack  of  individual  morale — a  moral  instability — forms  the 
soil  upon  which  the  other  predisposing  causes  grow  and  finally  blossom 
into  a  true  traumatic  neurosis  when  cultivated  by  the  exciting  cause. 

2.  Desire  for  Gain. — The  great  majority  of  traumatic  neuroses 
occur  among  those  seeking  compensation  for  their  injuries.  In  the 
days  of  personal  injury  suits  when  damages  for  $10,000  or  even  $25,000 
were  sought  and  the  trials  extended  over  a  period  of  months  or  years 
these  neuroses  were  far  more  prevalent  and  the  cure  more  difficult. 
Even  to-day  with  employees'  compensation  laws  the  cases  are  common. 
Fortunately  fixed  rates  of  compensation,  reducing  the  amount  of 
damages  which  can  be  collected,  and  early  payment  of  the  claim 
have  removed  this  predisposing  cause. 

If  compensation  commissions  would  recognize  the  true  nature  of 
these  cases  they  would  make  it  legally  impossible  for  the  payment 
of  claims  for  permanent  disability  on  grounds  of  "nervous  shock," 
"nervous  exhaustion"  or  any  form  of  neuroses.  The  compensation 
should  be  limited  to  the  organic  condition.  Weekly  compensation 
for  a  certain  period  for  the  neuroses  could  be  paid  but  after  their 
consultants  were  satisfied  that  a  neurosis  case  could  return  to  work 
further  payment  should  cease. 


OTHER    TRAUMATISMS    WITH    MEDICOLEGAL    ASPECTS        725 

The  fact  that  so  many  of  these  cases  recover  rapidly  after  the  claim 
is  paid  is  used  as  an  argument  by  many  that  the  employee  was  faking. 
Again  revert  to  the  child  who  develops  a  typical  neurosis,  with  sub- 
jective and  objective  symptoms,  and  who  soon  recovers  after  his  end 
is  gained.  Sometimes  it  is  necessary  and  best  to  grant  the  child's 
desire,  and  again  he  must  be  cured  by  making  it  quite  plain  that  he 
can  die  first  before  the  desired  toy  or  other  wish  is  granted.  Our 
neurosis  case  has  the  same  emotional  instability  and  must  be  handled 
according  to  his  individual  indications. 

The  desire  for  a  vacation;  or  the  desire  of  revenge,  as  when  a  doctor 
belittles  the  injury  and  the  patient  determines  to  "show  him  up;" 
pride,  pity,  pique  and  other  similar  emotions,  all  are  examples  of 
personal  gain  which  may  be  the  predisposing  factor. 

3.  Fear  and  Suggestion. — The  element  of  fear  and  fright  are  very 
strong  stimuli  for  the  development  of  neuroses.  A  serious  accident,  or 
witnessing  a  catastrophe,  with  no  or  very  little  injury  resulting, 
is  a  common  cause  for  these  conditions. 

Fear  of  pain  in  an  injured  part  may  cause  the  patient  to  cry  out  and 
wince  at  the  least  touch.  This  soon  becomes  a  habit  and  is  one  of  the 
most  difficult  forms  of  neurosis  to  overcome,  unless  carefully  treated 
from  the  very  beginning. 

Fear  of  serious  complications  will  often  cause  the  subjective, 
and  at  times  the  objective,  symptoms  of  the  dreaded  condition  to 
develop. 

Suggestion  is  often  the  breeder  of  fears  that  result  in  the  most 
serious  types  of  traumasthenias.  The  doctor  will  suggest  "internal 
injuries"  to  either  the  family  or  the  patient  direct;  or  he  will  talk 
freely  before  the  patient  of  the  serious  complications  which  developed 
in  another  patient  similarly  injured.  The  lawyer  can  subtly  suggest 
many  permanent  disabilities  and  very  shortly  is  gratified  to  see  these 
develop.  By  far  the  greatest  number  of  cases  of  traumatic  neuroses 
appearing  in  the  courts  have  undoubtedly  been  due  to  these  hetero- 
suggestions  from  physicians,  lawyers,  relatives  and  well  meaning 
friends  rather  than  to  autosuggestion  on  the  part  of  patients. 

Proof  of  this  is  amply  furnished  by  the  fact  that  injured  employees 
treated  in  hospitals  and  surrounded  by  proper  environment  under  the 
close  supervision  of  the  plant  surgeon  seldom  have  marked  neuroses. 

Neurasthenia,  and  even  hysteria  due  to  fear  and  suggestion  is  not 
limited  to  accident  cases.  The  suggestion  of  a  stomach  analysis  in 
order  to  rule  out  a  possible  cancer  or  ulcer  will  often  result  in  the  most 
prolonged  neurasthenic  state.  Rich  patients  who  can  afford  to 
run  from  one  doctor  to  another  with  every  minor  ailment,  collecting 
a  vast  store  of  fears  and  suggestions,  furnish  the  best  examples  of 
neurasthenia.     Such    patients    are    "cured"    by    Christian    Science 


726  INDUSTRIAL   MEDICINE    AND    SURGERY 

and  make  up  a  large  proportion  of  the  congregations  of  the  Scientist 
Church. 

4.  Psychic  Impressions. — Patients  who  have  been  in  serious  acci- 
dents, such  as  a  train  wreck,  a  falHng  elevator,  a  fire,  etc.,  without 
receiving  any  noticeable  injury  frequently  develop  neuroses.  Hys- 
teria and  malingering  more  often  result  from  such  accidents. 
Neurasthenia  will  follow  more  serious  injuries  in  which  serious  com- 
plications are  feared  but  do  not  develop.  If  such  injuries  are  received 
in  accidents  accompanied  by  frightful  sights,  sounds  or  other 
impressions,  this  type  of  neurosis  is  more  liable  to  occur.  Either 
psychic  trauma  or  real  injury  occurring  to  a  patient  who  has  been  under 
abnormal  stress  and  strain  or  to  an  emotional  person  having  the  so- 
called  "hysteric  temperament"  may  cause  the  development  of  any 
type  of  neurosis,  but  most  commonly  that  of  hysteria. 

5.  Race. — It  has  been  the  common  observation  of  all  authorities 
on  this  subject  that  the  Jewish  race,  especially  the  very  poor  or  the 
very  rich,  are  the  most  susceptible  to  neuroses.  This  is  undoubtedly 
due  to  the  emotional  temperament,  characteristic  of  the  Hebrew.  The 
condition,  however,  is  not  more  common  among  the  intelligent  Jews 
than  among  other  nationalities.  I  have  found  the  Irish  and  Italians, 
especially  among  the  very  poor  and  less  educated  classes,  also  quite 
susceptible  to  these  conditions. 

6.  Age  and  Sex. — I  have  cared  for  thousands  of  injuries  among 
girls  and  women  and  have  found  traumatic  neuroses  far  less  prevalent 
among  them.  They  develop  more  mild  neurasthenic  or  hysteric 
conditions  but  the  severe  forms  more  commonly  appear  among  the 
men.  On  the  other  hand,  hysteria  from  all  causes  oftener  affects 
women  than  men  and,  as  is  well  known,  this  type  is  commonest  at 
the  age  of  puberty  or  at  the  time  of  menopause.  The  traumatic 
neuroses  have  more  frequently  appeared  in  employees  over  the  age  of 
thirty  than  under  it,  in  my  experience. 

The  exciting  cause  for  these  traumatic  neuroses  is  an  accident 
which  results  in  a  real  or  imaginary  injury.  Such  injuries  may  occur 
to  any  part  of  the  body  and  may  vary  from  the  slightest  to  the  most 
severe  trauma.  Injuries  to  the  head,  abdomen  or  spine  more  fre- 
quently result  in  neurasthenia,  while  injuries  to  the  back  or  extremities 
are  more  commonly  the  cause  of  malingering.  No  one  regional  injury 
seems  to  produce  hysteria  more  than  another. 

"Traumatic  Neurasthenia"  and  "Traumatic  Hysteria"  are  the 
recognized  types  of  functional  neuroses  following  trauma.  The 
neurasthenic  and  hysteric  symptoms  developing  after  an  accident,  do 
not  differ  to  any  extent  from  the  functional  diseases  described  as 
neurasthenia  and  hysteria,  which  occur  without  the  exciting  cause  of 
trauma.     The  diagnosis  of  neurasthenia  is  not  nearly  so  common  as 


OTHER    TRAUMATISMS    WITH    MEDICOLEGAL    ASPECTS         727 

it  was  a  decade  ago  and  this  is  generally  because  better  diagnostic 
methods  have  revealed  a  real  organic  disease  in  many  of  these 
so-called  functional  states.  In  the  same  way  the  diagnosis  of 
traumatic  neurasthenia  is  becoming  less  common. 

The  functional  disease  known  as  hysteria  is  now  recognized  by 
many  as  a  mental  disease  and  the  stigma  or  signs  of  this  condition 
pre-existed  in  all  patients  who  later  develop  the  disease.  Traumatic 
hysteria,  therefore,  is  simply  the  combination  of  a  trauma  occurring  to 
a  person  with  this  pre-existing  stigma  and  thus  exciting  an  outbreak 
of  the  hysteria.  If  such  a  patient  gains  considerable  attention  or 
gains  a  large  compensation,  the  tendency  toward  a  recurrence  of 
traumatic  hysteria  is  increased.  In  fact  a  most  important  part  of  the 
treatment  of  these  traumatic  hysterias  depends  upon  the  handhng  of 
the  settlement.  Both  employers  and  compensation  commissions  often 
increase  the  hysteric  stigma  by  assuming  a  too  generous  attitude 
toward  such  patients. 

Traumatic  neurasthenia  on  the  other  hand  is  a  much  more  tangible 
condition.  The  patients  are  more  susceptible  to  reasoning  and  the 
tendency  to  recurrence  is  rare. 

A  most  complete  description  of  these  traumatic  neuroses  is  given 
in  Moorhead's  "Traumatic  Surgery"  and  the  reader  is  referred  to  this 
for  an  adequate  description  of  the  symptoms  and  diagnosis  of  these 
conditions. 

Treatment. — The  question  of  whether  these  neurotics  will  have 
prolonged  weekly  compensation,  terminating  finally  in  claims  for 
permanent  disabihty  depends  altogether  upon  the  handling  of  the 
case  by  the  surgeon.  If  his  suggestions  of  a  more  serious  trouble  than 
really  existed  has  been  the  predisposing  factor  in  the  condition,  or  if 
he  has  undiplomatically  antagonized  the  patient  by  accusing  him  of 
faking,  or  of  merely  "being  nervous,"  better  results  can  be  obtained 
by  changing  surgeons.  Patience,  tact,  cheerfulness  and  the  abihty 
to  inspire  confidence  are  essential  qualities  in  a  surgeon  who  would 
successfully  handle  traumatic  neuroses. 

We  must  recognize  that  a  certain  percentage  of  all  accident  cases 
wiU  possess  this  tendency  to  develop  neuroses,  therefore,  the  surgeon 
must  approach  every  emergency  case  in  such  a  manner  as  to  inspire  the 
confidence  of  the  patient  from  the  beginning.  If  he  shows  undue 
excitement,  assumes  a  grave  attitude,  hesitates  in  his  various  pro- 
cedures and  otherwise  shows  indecision  he  can  very  easily  plant  the  seeds 
for  "traumatic  neurasthenia."  Many  a  case  of  traumatic  hysteria 
receives  its  incentive  from  the  blustering  surgeon  who  gets  his  nurses 
and  assistants  greatly  excited,  who  starts  one  line  of  treatment  and 
discards  it  for  another,  talks  unguardedly  about  the  serious  nature  of 
the  case  and  finally  suggests  that  the  patient  should  go  to  a  hospital 


728  INDUSTRIAL   MEDICINE    AND    SURGERY 

but  ends  by  allowing  him  to  go  home.  In  other  words,  the  emergency- 
surgeon  must  be  a  person  quick  to  make  his  decisions  and  gentle  but 
firm  in  his  handling  of  the  case. 

The  best  treatment  of  traumatic  neurasthenia  is  to  remove  the 
patient  to  the  hospital  under  favorable  environment,  win  his  confidence 
and  then  by  a  frank  talk  and  careful  explanation  of  all  symptoms 
gradually  disperse  his  fears.  A  more  rapid  and  permanent  cure  can 
be  obtained  in  this  way  than  by  the  use  of  medicines  and  other  forms 
of  treatment.  During  this  period  the  injury  must  be  most  carefully 
handled  and  its  seriousness  must  not  be  too  greatly  belittled;  certainly 
it  must  never  be  exaggerated.  The  objective  symptoms,  chief  of 
which  are  pain  and  insomnia  must  be  combatted  often  with  medicine. 
Useful  and  interesting  bedside  studies  and  occupations  are  of  the 
greatest  benefit  in  these  cases  and  will  relieve  the  patient's  intro- 
spection, which  is  usually  the  basis  of  his  condition. 

The  traumatic  hysterias  should  likewise  be  removed  to  suitable 
environment;  the  successful  surgeon  will  draw  upon  his  imagination 
in  order  to  conceive  various  forms  of  subtle  suggestion  designed  to 
work  a  miraculous  cure.  Usually  the  friends  and  relatives  must  first 
be  convinced  of  the  hysterical  nature  of  the  trouble.  Unless  this 
is  done,  the  sympathy  and  suggestions  of  a  loving  relative  will  most 
likely  prolong  the  disease.  These  patients  will  present  various  emo- 
tional states,  which  can  best  be  combatted  by  the  surgeon  assuming 
similar  emotional  attitudes.  For  example,  the  cunning  in  the  hys- 
teric must  be  met  with  cunning  in  the  surgeon.  Every  effort  must 
be  made  to  win  the  confidence  of  these  patients  before  any  sudden 
cure  can  be  accomphshed.  Generally,  medication  is  seldom  indicated 
except  as  a  means  for  gaining  this  confidence.  The  local  symptoms 
such  as  pain,  paralysis,  contractures  and  special  sense  defects  must 
be  treated  both  medically  and  surgically,  always  with  the  view  of 
suggesting  a  cure.  It  is  quite  apparent  that  the  value  of  any  sug- 
gestive treatment  will  be  lost  if  the  antagonism  of  the  patient,  rather 
than  his  complete  confidence  is  aroused.  For  example,  if  one  of  these 
patients  develops  generahzed  convulsions  and  the  surgeon  in  disgust 
and  often  in  anger  appHes  extreme  pressure  on  certain  painful  areas, 
such  as  supra-orbital  regions  he  may  cut  short  the  attack  but  he  has 
aroused  a  certain  amount  of  antagonism  in  the  patient.  On  the  other 
hand,  if  he  gains  this  patient's  confidence  and  explains  to  him  that  a 
certain  type  of  painful  treatment,  such  as  this  pressure,  is  necessary 
to  accomplish  a  cure,  he  will  get  much  quicker  results. 

Shght  back  injuries  often  result  in  most  extreme  types  of  traumatic 
hysteria.  A  strained,  exaggerated  position  is  assumed  by  such  a 
patient  and  he  may  even  develop  a  paralysis  in  one  or  both  legs.  A 
careful  diagnosis  should  first  be  made  to  rule  out  all  signs  of  organic 


OTHER   TRAUMATISMS   WITH   MEDICOLEGAL   ASPECTS        729 

injury.  This  implies  the  use  of  the  aj-ray,  motor  and  sensory  tests,  etc. 
All  of  these  methods  of  examination  must  be  conducted  in  a  matter  of 
fact  way  so  as  not  to  arouse  further  suggestions  in  the  patient's 
mind  and  with  the  view  to  increasing  his  confidence  in  the  surgeon. 
After  the  diagnosis  of  hysteria  is  positively  proven  and  this  confidence 
is  estabHshed,  the  surgeon  can  direct  his  utmost  efforts  toward  com- 
batting the  hysteria,  and  the  more  sudden  and  miraculous  cure  which 
can  be  attained  the  more  certain  its  permanency.  Many  of  these  cases 
can  be  handled, successfully  in  the  following  manner: 

The  proven  hysteric  is  told  that  local  appHcations  of  heat  by 
special  instruments  are  necessary  to  cure  the  condition  and  such  treat- 
ment can  only  be  given  at  the  hospital.  After  arriving  at  the  hospital 
the  patient  is  prepared  for  the  treatment  by  certain  medication.  He 
is  told  that  the  medicine  is  very  nasty  but  must  always  precede  the 
application  of  heat.  He  is  given  a  large  dose  of  asafetida  followed 
immediately  by  "a  seidlitz  powder,  followed  a  few  minutes  later  by 
tr.  of  ammonium  valerinate.  This  administration  is  made  with  great 
solemnity  and  with  expressed  sympathy  for  the  person  who  must  take 
such  bitter  potions.  He  is  then  taken  to  the  dressing  room,  his  back 
or  paralyzed  limb  exposed  and  is  asked  to  point  out  the  place  where 
the  pain  or  trouble  seems  to  be  the  most  acute.  A  cutting  needle,  about 
2  inches  long  is  then  heated,  so  that  the  patient  can  see  it,  until  it  is 
red  hot,  when  it  is  suddenly  plunged  into  the  soft  tissues  and  imme- 
diately withdrawn.  The  real  pain  from  this  procedure  is  slight  but 
the  psychologic  effect  upon  the  patient  is  remarkable.  This  treat- 
ment is  not  carried  out  in  a  spirit  of  punishment.  It  has  been  sug- 
gested to  the  patient  innumerable  times  that  such  treatment  usually 
accomplishes  an  immediate  cure  and  I  have  found  it  seldom  necessary 
to  repeat  this  procedure. 

Electrotherapy  and  hydrotherapy  are  markedly  beneficial  in  many 
of  these  cases.  A  stream  of  cold  water,  shot  from  a  hose  pipe  with 
force,  against  the  affected  part  is  very  effective.  These  patients  can 
often  be  easily  hypnotized  and,  while  in  the  hypnotic  state,  the  para- 
lyzed limb  is  found  as  useful  as  the  other  Hmb.  The  patient  who  has 
not  walked  for  weeks  will  sometimes  be  cured  on  awakening  from  the 
hypnotic  state  and  finding  himself  standing  alone.  Anesthetized 
patients  can  be  similarly  treated.  I  have  seen  some  wonderful  cures 
by  merely  suggesting  that  the  next  day  the  patient  will  be  anesthetized 
and  the  contracted  hmb  forcibly  straightened.  On  the  surgeon's 
visit  the  next  day  the  condition  has  often  corrected  itself. 

The  following  case  history  will  illustrate  the  methods  which  must 
often  be  employed  to  successfully  combat  these  traumatic  hysterias: 

Mr.  M.,  55  years  old,  employed  as  a  mechanic  in  a  plow  factory, 
in  a  town  some  50  miles  from  Chicago,  was  struck  a  glancing  blow  on 


730  INDUSTRIAL    MEDICINE    AND    SURGERY 

his  left  shoulder  and  left  side  of  his  head  by  a  moving  crane.  He  was 
knocked  down  but  was  not  unconscious.  A  cab  was  called  and  he 
was  taken  to  the  doctor's  office,  where  an  examination  failed  to  reveal 
any  injury  except  a  slight  contusion  on  the  shoulder.  He  was  sent  home 
and  the  next  day  was  able  to  return  to  work.  That  night  the  surgeon 
was  hurriedly  called  to  his  home  because  the  patient  had  evidently 
had  a  stroke  of  paralysis.  The  surgeon  found  the  patient  suffering 
from  an  apparent  paralysis  of  the  left  arm  and  left  leg  and  with 
his  face  contorted  and  cyanotic  and  the  jaws  fixed  so  that  it  was  im- 
possible to  open  the  patient's  mouth.  This  condition  persisted  for 
several  hours  when  the  patient  finally  relaxed.  The  paralysis,  how- 
ever, persisted.  A  few  hours  later  he  had  another  attack,  and  this 
time  the  spastic  condition  involved  the  left  arm  and  left  foot.  It 
lasted  for  only  a  few  minutes  when  the  patient  again  relaxed.  These 
attacks  recurred  every  few  minutes  for  the  next  24  hours. 

The  local  surgeon  called  the  author  in  consultation.  When  I 
arrived  the  patient  was  resting  quietly  and  had  not  had  an  attack  for 
two  hours.  I  started  my  examination  but  on  lifting  the  paralyzed 
left  arm  an  attack  was  immediately  induced.  The  jaws  were  fixed, 
the  face  contorted,  and  the  eyes  open  and  staring.  The  left  fist  was 
tightly  contracted  while  the  left  arm  was  held  perfectly  rigid,  and  the 
toes  contracted.  Respiration  practically  stopped  and  the  patient 
became  very  cyanotic.  He  seemed  to  suffer  intensely.  The 
picture  this  man  presented  was  most  distressing  and  the  grief  of 
his  wife  and  one  of  his  daughters  was  uncontrolled.  Another  daughter, 
who  was  a  nurse,  sponged  her  father's  face  with  cold  water  and  tried 
in  other  ways  to  relieve  the  condition.  The  son,  who  was  present, 
expressed  himself  bitterly  toward  the  concern  responsible  for  his 
father's  condition.     The  paroxysm  lasted  about  two  minutes. 

There  were  no  facilities  for  x-ray  examination  in  this  town  and  I 
recommended  that  the  patient  be  brought  at  once  to  Chicago  and  put 
in  a  hospital  where  his  case  could  be  thoroughly  studied.  This  plan 
was  agreed  to  and  arrangements  were  quickly  made  to  take  the  pa- 
tient on  the  next  train  which  left  within  an  hour.  During  the  excite- 
ment of  getting  ready  the  patient  had  only  two  attacks.  He  was 
carried  to  the  train  on  a  cot  and  placed  in  the  baggage  car,  the  surgeon 
and  the  son  riding  with  him.  He  had  no  attacks  on  his  way  to  the 
city. 

Immediately  after  arriving  at  the  hospital  these  attacks  returned 
and  occurred  at  frequent  intervals.  An  x-ray  examination  failed  to 
show  any  signs  of  injury  and  after  a  study  of  the  case  for  a  few  hours 
a  diagnosis  of  hysteria  brought  on  by  the  slight  trauma  was  made. 

It  was  quite  evident  that  the  family,  especially  the  daughter  who 
was  a  nurse,  could  not  easily  be  convinced  that  their  father  was  simply 


OTHER   TRAUMATISMS    WITH    MEDICOLEGAL    ASPECTS         731 

suffering  from  hysteria.  Therefore,  I  decided  a  miraculous  cure  was 
necessary.  Within  48  hours  I  had  gained  the;  imphcit  confidence 
of  the  patient  and  the  family,  which  was  primarily  essential  in  the 
handling  of  such  a  case. 

By  this  time  the  attacks  were  infrequent.  It  was  suggested,  how- 
ever, in  the  patient's  presence  that  he  could  easily  be  thrown  into 
an  attack  by  endeavoring  to  forcibly  close  his  left  fist.  Each  time 
that  the  nurse,  interne  or  surgeon  attempted  this  procedure  the  patient 
would  immediately  develop  a  paroxysm.  I  then  carefully  explained  to 
the  patient  that  the  attacks  could  be  prevented  by  the  use  of  a  certain 
expensive  drug  which  I  had  ordered  and  which  would  be  delivered 
the  next  day.  Both  the  nurse  and  the  interne  expressed  great  im- 
patience in  the  presence  of  the  patient  for  the  arrival  of  this  drug. 
The  next  day  I  appeared  with  a  small  bottle  of  quinin  sulphate.  The 
method  of  procedure  was  then  carefully  explained  to  the  patient. 
He  was  to  put  his  tongue  out  in  order  that  I  might  coat  it  over  with 
this  medicine;  at  the  same  time  he  was  to  forcibly  press  on  his  right 
ear  with  his  right  hand  and  elevate  his  right  leg  at  an  angle  of  about 
45  degrees  and  hold  it  in  that  position  until  the  medicine  took  effect. 
Meanwhile  I  would  forcibly  close  his  left  fist,  but  "because  of  the  drug 
and  the  effect  on  his  circulation  of  these  various  acts  on  his  part,  no 
attack  would  develop."  The  plan  was  carried  out  and  with  great 
success.  He  complained  of  the  bitter  medicine  but  was  greatly  grati- 
fied by  its  wonderful  effect.  A  short  time  later,  without  the  use  of 
the  medicine  or  of  elevating  the  leg  and  pressing  the  ear,  we  tried 
to  close  his  left  fist  and  an  attack  immediately  developed.  The  above 
line  of  treatment  was  then  again  carried  out  successfully.  This  was 
repeated  several  times  until  I  was  convinced  that  the  patient  was 
thoroughly  imbued  by  the  suggestion. 

One  of  the  best  nerve  speciahsts  of  the  city  was  then  called  in 
consultation.  The  patient  was  thrown  into  an  attack  by  pressure  on 
the  left  fist  and  from  the  symptoms  and  history  of  the  case 
the  specialist  agreed  with  the  diagnosis  of  traumatic  hysteria.  The 
entire  family  was  present  during  this  consultation  and  for  this  reason 
the  specialist  was  warned  against  telHng  them  at  that  time  the  nature 
of  the  condition.  After  he  had  completed  his  examination  I  told  the 
family  and  the  specialist  of  the  wonderful  cure  which  I  had  effected 
by  means  of  this  drug  and  proceeded  to  demonstrate  the  method  to 
them.  It  was  again  successful.  I  then  suggested  to  the  patient  that 
the  same  effect  could  be  achieved  by  holding  his  right  leg  in  the  au-, 
pressing  on  his  ear,  sticking  out  his  tongue,  without  using  any  of  the 
medicine  and  again  the  results  were  successful.  It  was  now  time  to 
tell  the  family  and  the  patient  the  nature  of  his  trouble.  The  bottle 
of  medicine  was  shown  to  them  and  they  were  told  that  it  was  nothing 


732  INDUSTRIAL   MEDICINE    AND    SURGERY 

but  old  fashioned  quinin.  The  daughter,  who  was  a  nurse,  verified 
this  statement  by  tasting  of  it  and  by  asking  the  hospital  nurse  and 
interne  if  this  were  true.  She  completed  the  cure  by  turning  to  the 
other  members  of  the  family  and  stating  that  their  father  had 
been  fooling  them.  By  this  time  the  patient  was  in  tears  and  was 
greatly  distressed.  I  immediately  sent  the  family  from  the  room  and 
comforted  him,  meanwhile  assuring  him  that  he  had  had  a  real  con- 
dition from  which  he  had  been  cured  and  that  now  he  could  get  up  and 
walk.  His  clothes  were  brought  and  in  a  short  time  I  led  him  out  to 
the  family,  a  well  man. 

The  details  of  this  case  are  set  forth  in  order  to  demonstrate  the 
essential  factors  in  rapidly  curing  this  type,  and  most  other  types, 
of  traumatic  hysteria. 

These  essentials  are:  (1)  An  early  but  positive  diagnosis  of  the 
condition;  (2)  securing  the  absolute  confidence  of  the  patient  and  the 
family;  (3)  removing  the  patient  to  a  hospital  where  his  entire  environ- 
ment can  be  carefully  supervised ;  (4)  ingeniously  devising  a  line  of  treat- 
ment which  will  carry  the  greatest  amount  of  suggestion  and  which 
usually  involves  some  foolish  act  on  the  part  of  the  patient  which  can 
later  be  used  to  demonstrate  the  fooHsh  nature  of  the  disease  to  both 
the  patient  and  the  family;  (5)  securing  a  sudden  and  miraculous  cure; 
(6)  selling  the  cure  to  the  relatives  and  friends. 

Many  cases  of  traumatic  hysteria  can  be  cured  without  the  pay- 
ment of  compensation  if  the  surgeon  will  familiarize  himself  with 
the  special  psychological  conditions  which  apply  in  each  case.  These 
analyses  require  individual  handling  and  no  hard  or  fast  rules  can 
be  laid  down  which  are  applicable  to  the  entire  group. 

MALINGERING 

Malingering  takes  one  of  two  forms.  It  is  either  a  combination 
of  hysteria  or  neurasthenia  with  subtle  faking,  or  pure  faking.  To 
call  all  malingerers  downright  fakers  is  misleading  and  will  often  cause 
the  surgeon  to  overlook  the  neurasthenic  and  hysteric  conditions, 
which  very  frequently  are  combined  with  the  malingering.  On  the 
other  hand,  deliberate  faking  of  both  subjective  and  objective  symp- 
toms occurs  frequently  without  any  evidence  of  organic  or  functional 
disease.  The  patient  deliberately  lies  in  order  to  accomplish  his  end, 
which  is  usually  that  of  gain  or  revenge.  I  prefer,  therefore,  to  divide 
these  malingerers  into  two  classes:  First,  the  true  mahngerer  and 
second,  the  absolute  faker. 

True  malingering  manifests  itseK  frequently  in  cases  of  fracture  or 
severe  strain,  or  other  injury  which  requires  several  weeks  of  con- 
valescence accompanied  by  very  little  pain.     These  patients  become 


OTHER   TRAUMATISMS   WITH   MEDICOLEGAL   ASPECTS        733 

hospitalized,  that  is,  they  enjoy  the  hfe  of  ease  in  the  hospital,  in- 
centive is  lost,  and  they  dread  returning  to  work.  All  manner  of 
symptoms  are  feigned,  usually  with  two  ends  in  view:  first,  to  prolong 
their  stay  at  the  hospital  or  their  period  of  absence  from  work;  second, 
to  develop  a  case  of  permanent  disability  with  the  view  of  collecting 
full  compensation. 

In  a  large  ward,  occupied  chiefly  by  railroad  employees,  I  have  seen 
this  type  of  mahngering  spread  like  an  epidemic.  A  congenial  group 
of  these  men  happen  in  the  hospital  at  the  same  time;  they  enjoy  smok- 
ing and  playing  cards  together  and  lose  all  desire  to  go  home.  The 
surgeon  must  ever  be  watchful  for  symptoms  of  this  type  of  malinger- 
ing. Ward  occupations,  wholesome  entertainment  and  often  puni- 
tive treatment,  administered  with  the  greatest  kindness,  are  necessary 
to  overcome  hospital  malingering. 

To  successfully  handle  malingerers  it  is  necessary  to  let  the  patient 
think  he  is  fooling  you.  Sympathize  with  him  and  by  suggestion  assist 
him  in  exaggerating  his  symptoms  more  and  more.  ''Give  the  calf 
plenty  of  rope  and  he  will  hang  himself"  applies  most  aptly  to  these 
cases.  Even  relatives  who  at  first  believe  in  the  true  nature  of  the 
patient's  complaints  will  soon  come  to  reahze  that  he  is  exaggerating  his 
trouble,  if  not  faking  it.  Some  cases  of  mahngering  can  be  nipped 
in  the  bud  by  immediately  demonstrating  that  the  patient  has  hed, 
followed  by  a  severe  arraignment.  This  line  of  treatment,  however, 
should  not  be  followed  unless  the  surgeon  is  quite  positive  he  can 
cure  the  condition  by  severely  lecturing  the  patient.  If  you  fail 
in  obtaining  an  immediate  cure  you  have  antagonized  the  man,  put 
him  on  his  guard  and  will  have  greater  difficulty  in  showing  him  up 
later  on.  The  following  case  demonstrates  one  of  the  best  methods 
of  handling  these  malingerers: 

S.  B . ,  male,  40  years  old,  stepped  backward  into  an  open  elevator  shaft 
while  working  in  the  basement  and  fell  to  the  bottom  of  the  shaft 
some  six  feet  below.  A  truck  which  he  was  pulhng  at  the  time  also 
fell  into  the  shaft  but  did  not  strike  the  employee.  Two  fellow 
employees  immediately  lifted  him  out  of  the  shaft  and  he  was  brought 
to  the  doctor's  office.  Examination  failed  to  reveal  any  serious  injury 
but  he  had  sustained  considerable  bruising  over  his  right  buttocks. 
He  complained  bitterly  of  his  symptoms  and  immediately  gave  evi- 
dence of  an  emotional  temperament  with  a  hysterical  tendency.  On 
account  of  this  he  was  persuaded  to  go  to  the  hospital.  He  was  kept 
in  bed  for  three  days  and  was  then  told  he  could  get  up  and  walk 
around  the  ward.  On  attempting  to  walk  he  showed  a  very  exagger- 
ated limp.  I  sympathized  with  the  patient  and  told  the  interne  in  the 
patient's  presence  that  he  undoubtedly  had  developed  "mock-mahgn 
syndrome"  and  most  probably  would  lose  the  sense  of  feeling  in  the 


734  INDUSTRIAL    MEDICINE    AND    SURGERY 

affected  leg,  or  would  be  bent  over  sidewise,  and  made  other  ridiculous 
suggestions.  The  next  day  I  submitted  this  patient  to  a  thorough 
examination  conducting  it  with  a  great  deal  of  solemnity  and  aiding 
him  by  suggestion  to  exaggerate  his  symptoms  more  and  more.  He 
complained  of  severe  pain  on  pressure  over  the  back  and  the  painful 
points  were  carefully  marked  with  a  pencil  as  he  pointed  them  out. 
Other  regions  were  examined  and  then  the  back  re-examined,  with  the 
result  that  the  patient  could  not  accurately  relocate  the  same  spots. 
Painful  spots  were  similarly  found  in  the  leg  and  the  different 
"relocation  areas"  marked.  The  pin-prick  test  showed  areas  of 
anesthesia  in  the  leg.  These  were  also  marked  and  similar  tests 
applied  later  on  with  the  result  that  the  anesthetic  areas  had  shifted. 
These  tests  were  made  with  the  patient  lying  down  so  that  he  could  not 
see  the  inaccuracy  of  his  statements.  The  patient  was  then  told  to 
stand  up,  place  his  feet  together,  throw  his  head  back  and  close  his 
eyes,  the  surgeon  meanwhile  holding  his  body  steady.  The  interne 
was  told  to  stand  behind  the  patient  and  catch  him  if  he  fell  backward 
"which  they  usually  did  when  suffering  from  this  particular  disease." 
On  letting  go  of  the  patient  he  immediately  fell  backward  into  the 
interne's  arms.  This  was  repeated  several  times.  It  was  now  time 
to  expose  the  frauds  which  the  patient  thought  he  was  perpetrating. 
He  was  again  placed  with  his  feet  together  and  his  head  back  and  this 
time  the  interne  was  told  to  "stand  aside  and  let  the  patient  fall  to  the 
floor  and  break  his  neck  if  he  wanted  to  for  he  was  only  faking  the 
symptoms  anyway."  Upon  saying  this  the  patient's  body  was  released 
and  he  was  told  to  go  ahead  and  fall,  but  he  never  did.  The  inaccuracy 
of  the  relocation  tests  were  pointed  out  and  it  was  carefully  explained 
how  we  had  deliberately  allowed  him  to  think  he  was  fooling  us.  A 
careful  record  of  his  case  had  been  kept  and  this  was  read  to  him  in 
order  to  prove  that  we  could  refute  any  claim  for  disability  which  he 
intended  to  make.  He  was  then  told  that  if  he  returned  to  work  at 
once  his  job  was  waiting  for  him  and  nothing  would  be  said  about  his 
attempted  fraud.  On  the  other  hand,  if  he  persisted  in  his  faking  he 
would  not  only  lose  further  compensation  but  his  job  as  well.  The 
next  day  Mr.  B.  returned  to  work. 

The  final  examination  as  above  described  was  conducted  in  the 
presence  of  his  wife  and  brother,  I  have  found  it  always  much  better 
to  expose  the  patient's  malingering  in  the  presence  of  his  relatives  as 
it  chagrins  the  patient  more  and  usually  convinces  the  relatives  of 
the  true  condition. 

The  majority  of  malingering  cases  develop  after  injury  to  an  ex- 
tremity, especially  involving  a  joint,  as  the  knee,  shoulder,  ankle  and 
hip  joints.  Slight  injury  to  the  back  is  also  a  frequent  cause  for  ma- 
lingering.    Careful  study  of  the  motions  of  a  "stiff  joint"  will  reveal 


OTHER    TRAUMATISMS    WITH    MEDICOLEGAL    ASPECTS         735 

that  the  patient  is  using  it  when  his  attention  is  otherwise  diverted. 
Likewise  a  careful  study  of  the  Ump  which  he  develops  will  show  many 
variations  in  it.  The  surgeon  must  become  a  veritable  detective  in 
order  to  catch  these  malingerers  off  their  guard.  When  sufficient 
evidence  of  the  faking  has  been  collected  the  surgeon,  who  up  to  this 
time  has  been  very  sympathetic,  can  turn  on  the  patient  in  righteous 
indignation  and  usually  succeed  in  convicting  him  of  fraud. 

In  the  cases  of  absolute  faking,  both  the  subjective  and  objective 
symptoms  are  deliberately  planned  with  the  intent  to  deceive.  Such 
patients  must  be  handled  as  described  for  malingering  and  the  cure 
always  depends  upon  discovering  the  fraud  and  exposing  the  patient. 

Besides  faking  the  symptoms,  these  employees  may  deliberately 
injure  themselves  in  order  to  gain  their  end,  which  is  usually  more 
compensation.  This  type  of  faking  is  best  illustrated  by  the  case 
of  J.  D.,  whom  we  operated  for  a  so-called  traumatic  hernia.  The 
stitches  were  removed  on  the  eleventh  day  and  the  wound  was  perfectly 
cleap.  Four  days  later  it  was  infected,  having  considerable  pussy  dis- 
charge. This  infection  resisted  all  treatment.  A  week  later  I  ar- 
rayed the  wound  in  order  to  make  sure  that  no  foreign  material  could 
have  been  left  in  the  tissues,  which  as  you  know,  is  very  unlikely  in  a 
hernia  operation.  The  x-ray  showed  a  pin  buried  in  the  upper  end  of 
the  wound.  This  was  removed  without  much  difficulty  but  the  patient 
was  not  told  about  it.  A  few  days  later  the  pussy  discharge  had  ceased 
but  the  wound  in  the  skin  was  not  completely  healed.  The  patient 
was  allowed  to  go  home,  however,  and  instructed  to  report  to  the 
doctor's  office  for  subsequent  dressings.  A  week  later  the  wound 
again  became  infected  and  began  to  discharge  profusely.  It  was  ex- 
plored by  forceps  and  several  small  bits  of  rags  were  removed.  With- 
out saying  anything  to  the  patient,  who  was  a  boy  of  only  eighteen,  his 
father  and  mother  were  sent  for  and  the  history  of  the  case  told  to 
them.  The  pieces  of  rag  removed  from  the  wound  were  shown  to  the 
mother,  and  she  indentified  them  as  parts  of  her  dish  towel,  which  she 
had  noticed  recently  had  been  cut.  They  were  naturally  indignant 
at  the  son  and  left  determined  to  punish  him  for  his  act.  On  reaching 
home,  however,  they  found  that  the  boy  had  packed  his  clothes  and 
left.  He  was  found  a  month  later,  living  in  Michigan  with  an  old 
bachelor  who  had  shared  his  room  at  the  hospital.  Detectives  placed 
on  the  case  found  that  this  bachelor  was  a  pervert  who  had  misled 
the  boy. 

I  realize  that  the  above  description  of  traumatic  neuroses  very 
inadequately  covers  this  subject.  However,  I  have  endeavored  to 
point  out  the  most  important  facts  about  these  conditions  which  the 
surgeon  in  industry  should  know  in  order  to  successfully  handle  a 
situation  which  is  very  common  in  industrial  practice. 


736  INDUSTRIAL    MEDICINE    AND    SURGERY 

TRAUMATIC  APOPLEXY 

Bollinger  has  described  certain  cases  of  cerebral  apoplexy  which 
occur  some  days  after  a  head  injury.  We  realize  that  severe  trauma 
often  is  responsible  for  a  middle  meningeal  hemorrhage  or  other  serious 
intracranial  heniorrhage.  In  such  cases,  the  nature  of  the  wound  and 
usually  the  finding  of  the  condition  at  autopsy  place  these  in  the  proper 
category  of  compensable  conditions  due  to  accident. 

The  later  development  of  apoplexy,  however,  after  a  head  injury 
is  more  often  due  to  the  systemic  conditions  ordinarily  the  cause  of  a 
"stroke  of  apoplexy,"  and  the  trauma  should  be  regarded  as  coinci- 
dental. Because  of  the  liability  of  such  a  claim  I  insist  upon  a 
thorough  physical  examination,  including  blood-pressure  in  all  cases 
of  head  injury.  Recently  an  employee  fell  and  sustained  a  scalp 
wound.  He  was  a  man  fifty  years  of  age,  very  fat  and  the  general  ex- 
amination showed  albumen  in  his  urine  and  a  blood-pressure  of  220. 
It  was  utterly  inconceivable  to  connect  this  systemic  condition  with 
the  injury  which  occurred  just  an  hour  previously.  This  employee 
recovered  from  the  scalp  wound  but  a  month  later  died  from  a  stroke 
of  apoplexy.  The  record  of  our  careful  examination  at  the  time  of 
injury  enabled  this  concern  to  refute  the  claim  of  traumatic  apoplexy. 

It  frequently  happens  that  a  person  will  fall  while  at  work,  or  will 
fall  from  the  step  of  a  street  car,  or  into  an  exposed  gutter  while 
walking  in  the  street.  When  picked  up  it  is  found  that  he  has  suffered 
a  stroke  of  apoplexy  and  has  sustained  an  injury  to  his  head.  The 
question  immediately  arises:  was  the  injury  responsible  for  the  apo- 
plexy or  was  it  sustained  as  a  result  of  his  falling  when  the  stroke 
occurred?  From  the  medicolegal  standpoint  such  cases  will  often 
present  themselves  for  solution.  An  injury  to  the  head,  sufficiently 
serious  to  rupture  the  small  calibered  "artery  of  apoplexy"  will  cer- 
tainly rupture  other  blood-vessels  nearer  the  site  of  the  injury.  If  the 
patient  is  not  dead  the  general  examination  will  show  the  high  blood- 
pressure  and  other  signs  of  the  apoplectic  state.  If  dead,  the  autopsy 
will  reveal  these  signs  as  well  as  the  typical  apoplexy. 

The  surgeon  in  industry  should  constantly  watch  for  these  obscure 
conditions  in  injured  employees  which  may  later  be  the  basis  for  an 
unjust  claim  for  compensation. 

TRAUMATIC  APPENDICITIS 

I  have  seen  several  cases  in  which  appendicitis  developed  a  few  days 
after  trauma  to  the  abdomen  and  were,  therefore,  made  the  basis  of 
claims  for  compensation.  On  only  one  occasion  have  I  felt  justified 
in  even  remotely  connecting  the  trauma  with  the  inflamed  appendix. 
This  occurred  in  a  small  boy  who  was  run  over  by  an  automobile,  the 


OTHER    TRAUMATISMS    WITH    MEDICOLEGAL    ASPECTS         737 

wheels  passing  directly  across  the  middle  of  the  abdomen.  The  skin 
was  abrased  and  contused  over  the  appendix  regions.  I  have  de- 
scribed this  same  case  in  the  chapter  on  "Compensable  Hernia"  as  the 
boy  also  developed  a  hernia  following  this  injury.  Three  days  after 
the  accident  he  complained  of  severe  abdominal  pain  in  the  region  of 
the  appendix.  This  was  followed  by  vomiting,  rigidity,  tenderness 
and  temperature.  The  leukocyte  count  rapidly  mounted  to  26,000. 
At  first  it  was  thought  that  the  symptoms  might  have  some  connection 
with  the  hernia  on  the  left  side  but  it  was  soon  evident  that  we  were 
dealing  with  a  case  of  appendicitis.  He  was  operated  ten  hours  after 
the  attack  began  and  a  swollen,  acutely  inflamed  appendix  removed. 
There  were  no  adhesions  or  other  signs  of  a  pre-existing  appendicitis. 
The  lumen  of  the  appendix  was  filled  with  soft  fecal  matter  but  there 
were  no  fecal  concretions.  Microscopically  the  changes  were  those  of 
acute  inflammation  of  the  appendix.  There  was  no  history  of  abdomi- 
nal colic,  "sick  stomach"  or  similar  conditions  which  might  indicate  a 
former  appendicitis.  Two  of  the  best  surgeons  in  Chicago  saw  this 
case  with  the  author  and  agreed  that,  while  it  was  quite  probable 
the  appendicitis  was  only  coincidental  yet  it  was  impossible  to  prove  to 
the  satisfaction  of  the  family  or  any  jury  that  the  trauma  was  not  the 
direct  cause  of  the  condition.  It  may  be  of  interest  to  know  that  this 
boy  developed  an  acute  intussusception  just  a  year  after  this  accident 
and  was  operated  by  another  surgeon.  He  died  following  the  opera- 
tion. The  family  felt  that  this  condition  was  the  result  of  the  previous 
injury  but  the  surgeons  who  handled  the  case  felt  that  the  previous 
injury  was  only  a  coincidence. 

Dr.  Charles  Rowan  who  saw  the  above  patient,  told  the  author  of 
a  case  of  traumatic  appendicitis  which  he  had  seen  in  the  County  Hos- 
pital some  time  before.  This  also  occurred  in  a  boy  of  six  years.  The 
youngster  fell  from  a  tree  and  struck  a  picket  fence,  causing  a  severe 
laceration  directly  over  the  appendix  region.  Two  days  later  he  devel- 
oped an  attack  of  acute  appendicitis  which  was  verified  on  operation. 
There  were  no  pathologic  findings  which  indicated  a  previous  attack 
of  appendicitis. 

The  majority  of  claims  for  this  conditiori,  however,  develop  in 
eases  where  the  nature  of  the  injury  to  the  abdomen  is  not  at  all  serious. 
Careful  questioning  will  reveal  the  fact  that  the  patient  has  had  abdomi- 
nal symptoms  previous  to  the  trauma.  In  other  cases,  the  attack 
develops  several  weeks  after  the  injury  and  during  the  interval  there 
were  no  manifestations  of  intra-abdominal  disturbance. 

Sprengle,  Deaver,  Moorhead  and  others  who  have  written  on  this 
subject  feel  that  it  is  scientifically  impossible  to  trace  the  relationship 
between  appendicitis  and  trauma  no  matter  how  serious  the  latter 
may  be.     When  we  consider  how  protected  this  tiny  organ  is  and  how 

47 


738  INDUSTRIAL   MEDICINE    AND    SURGERY 

much  more  readily  the  larger  abdominal  viscera  could  be  injured  it  is 
very  difficult  to  conceive  of  a  trauma  having  any  etiological  element 
in  the  development  of  an  attack  of  appendicitis.  As  Moorhead  has 
so  aptly  pointed  out  "the  abdominal  violence  may  occasionally  act  as 
an  alarm  clock  for  the  re-awakening  of  a  dormant,  inflamed  appendix." 

TRAUMATIC  DISPLACEMENTS  OF  THE  UTERUS 

Girl  employees  very  frequently  complain  of  displacements  of  the 
womb  as  a  result  of  injury.  In  my  experience  the  commonest 
causes  for  these  claims  are  such  accidents  as  falling  down  stairs, 
or  being  forcibly  knocked  down  by  some  fellow  employee  run- 
ning through  the  aisle,  by  a  truck,  or  an  automobile.  Practically 
every  one  of  these  claims  develops  after  the  girl  employee  has 
consulted  the  family  physician;  or  quite  frequently  after  some  lady 
physician  has  told  her  that  a  displaced  womb  has  resulted  from  the 
accident.  Often  this  statement  is  made  by  the  family  physician  with- 
out a  vaginal  or  rectal  examination  being  made.  These  girls  will  com- 
plain of  severe  pain  in  the  back  and  of  painful  menstrual  periods,  both 
of  which  "never  existed  prior  to  the  injury."  All  such  cases  should  be 
submitted  to  a  thorough  pelvic  examination.  This  should  always  be 
done  in  the  presence  of  the  mother  or  a  lady  relative  and  a  nurse  and 
preferably  with  the  patient  anesthetized  with  nitrous  oxid.  Where 
this  has  been  done,  I  have  never  found  a  case  which  showed  the  uterus 
displaced  except  in  two  older  women,  both  of  whom  showed  other 
evidence  of  a  displacement  of  long  standing,  such  as  relaxed  vaginal 
walls,  and  in  one  a  definite  cystocele  and  rectocele. 

Personally,  I  am  convinced  that  a  permanent  displacement  of  the 
uterus  never  follows  direct  violence.  It  is  conceivable  that  such  a 
violence  might  cause  a  temporary  displacement  but  the  organ  would 
undoubtedly  almost  immediately  resume  its  normal  position.  Pelvic 
symptoms  may  follow  severe  trauma  in  the  region  of  the  pelvis  as  a 
result  of  this  temporary  displacement  and  these  must  be  treated  by  rest 
and  other  means,  often  requiring  temporary  disability  such  as  may 
follow  any  strain.  The  only  compensation,  therefore,  which  should 
be  paid  such  cases  is  for  this  temporary  disability.  It  is  often  cheaper 
in  doubtful  cases  to  repair  the  condition,  paying  compensation  for  the 
time  lost  from  work,  just  as  in  the  case  of  doubtful  hernias,  rather 
than  allow  the  condition  to  persist  with  the  subsequent  claims  for  per- 
manent compensation. 

TRAUMATIC  ORCHITIS 

This  condition  may  develop  from  falls,  blows  and  other  forms  of 
direct  violence  to  this  organ.  Frequently,  however,  employees  will 
report  to  the  doctor's  office  with  a  swollen  testicle,  exceedingly  painful,, 


OTHER    TRAUMATISMS    WITH    MEDICOLEGAL    ASPECTS         739 

which  they  claim  is  due  to  an  injury,  or  more  often  to  a  severe  strain 
while  lifting.  If  careful  examination  is  made,  a  gonorrheal  infection 
will  be  discovered  in  many  of  these  cases,  thus  showing  the  real  cause 
of  the  condition.  The  important  point,  therefore,  in  traumatic  orchitis 
is  to  always  make  sure  that  gonorrhea  is  not  present.  However,  a 
direct  violence  to  the  testicle  even  in  a  gonorrheal  patient  may  furnish 
cause  for  compensation. 

The  above  examples  are  sufficient  to  illustrate  the  number  of 
remote  conditions  associated  with  trauma  which  can  develop  and 
which  present  medicolegal  aspects.  It  is  very  evident,  therefore, 
that  the  surgeon  in  industry  must  acquire  a  keen  medicolegal  sense. 
Above  all  he  must  not  let  his  desire  to  discover  false  claims  prejudice 
his  judgment  against  the  true  compensable  traumatic  conditions. 


.     ,  CHAPTER  XLV 

I  HEALTH  INSURANCE 

Twenty-five  years  ago  in  my  father's  little  factory,  employing 
some  50  people,  every  man  knew  "John"  and  father  knew  them. 
The  friendliest  human  relations  existed  between  him  and  his  hands 
because  of  the  personal  touch  which  could  be  maintained.  Labor 
turn-over  was  small  because  the  men  were  satisfied.  If  one  of  these 
employees  became  sick,  or  sickness  assailed  some  member  of  the 
family  he  usually  dropped  in  to  see  if  anything  was  needed. 
Often  financial  help  was  the  most  urgent  need.  Money  was  freely 
advanced,  which  could  be  paid  back  in  small  installments  after  the 
existing  emergency  had  passed. 

With  the  growth  of  industry  and  the  combination  of  these  small 
factories  into  one  gigantic  concern  this  personal  relationship  between 
employer  and  employee  was  lost.  The  president  of  the  concern 
replaced  the  old  proprietor,  the  general  superintendent  replaced  the 
"boss"  and  the  "hands"  became  human  machines.  They  missed 
the  old-time  contact  with  the  head  of  the  firm  and  the  seeds  of  dis- 
satisfaction and  distrust  were  sown,  later  to  bear  fruit  in  "labor 
troubles." 

During  the  early  days  when  industrial  enterprises  in  this  country 
were  expanding  at  a  terrific  rate  the  employers  were  absorbed  in  a 
fierce  battle  for  their  survival.  This  was  interpreted  as  selfishness 
by  the  employees  and  unfortunately  in  many  cases  it  was  a  true 
interpretation.     Labor  began  to  combine  and  battle  for  its  survival. 

Since  the  old  friendliness  between  the  boss  and  his  men  had  died 
labor  unions  began  to  replace  it.  Sick  funds  were  created  and 
when  one  of  the  members  was  forced  to  remain  away  from  work 
on  account  of  illness  he  was  given  aid  from  this  fund.  Those  employ- 
ees not  so  fortunate  as  to  belong  to  the  labor  union  class  were  often 
left  destitute  when  sickness  attacked  them.  Humanity  recognized 
that  some  assistance  must  be  rendered  these  unfortunates  and  their 
families  and  charitable  organizations  sprang  into  being.  Now 
practically  every  city  has  its  Associated  Charities. 

About  fifteen  years  ago  a  few  large  industries,  with  a  far-sightedness 
that  was  interpreted  by  many  as  "fads, "  "  philanthropy, "  "  conscience- 
easers,"  and  similar  states  of  mind,  began  to  recognize  that  something 
was   wrong  in  this  economic  arrangement.     These  men  began  to  re- 

740 


HEALTH    INSURANCE  741 

establish  the  human  relationship  between  employer  and  employee.  It 
was  impossible  for  the  executive  to  become  intimate  with  his  thousands 
of  employees  and  to  show  a  personal  interest  in  their  welfare,  but  he 
could  utilize  different  agencies  to  represent  him  in  this  new  relationship. 

The  results  of  this  new  viewpoint  showed  that  a  good  business 
sense  rather  than  philanthropy  was  behind  all  such  movements. 
However,  this  relationship  was  never  successful  when  based  on  a 
selfish  foundation;  the  mutual  welfare  of  each  was  the  absolutely 
essential  motive,  guided  always  by  the  spirit  of  the  Golden  Rule. 

In  ever  increasing  numbers  have  the  industries  of  the  country 
adopted  this  new  spirit  and  with  its  growth  labor  troubles  have  been 
decreasing.  But  at  the  outbreak  of  the  war  the  old  selfish  attitude 
on  the  part  of  both  industry  and  labor  was  still  predominant.  The 
necessity  of  speeding  up  production  in  order  to  supply  our  armies 
with  the  sinews  of  war  is  resulting  in  recognition  of  the  human 
engineering  processes  advocated  for  many  years  by  many  workers 
in  this  field  and  which  have  been  successfully  applied  in  several 
instances. 

Disease  is  our  common  enemy.  It  arouses  sympathy  for  our 
assailed  brother  and  wins  his  gratitude  when  assistance  is  offered  at 
such  a  time.  On  this  account  good  medical  and  surgical  aid  provided 
by  the  employer  for  his  employees  has  proven  to  be  the  best  human- 
izing agency  ever  introduced  into  industry.  And  as  one  of  our  greatest 
business  men  has  said:  "The  medical  departnient  pays  the  biggest 
dividends." 

No  other  one  factor  has  been  so  potent  in  calling  the  attention 
of  our  people  to  the  waste  in  human  life  and  human  energy 
as  this  medical  work  in  industries.  It  has  paved  the  way  for  several 
momentous  advances  in  preventive  medicine  and  preventive  surgery. 
It  has  provided  methods  for  excellent  care  of  the  sick  and  injured 
employees.  But  it  is  greatly  handicapped  in  its  work  of  mercy  by 
the  lack  of  financial  support  of  the  employee  during  his  time  of  forced 
idleness  due  to  sickness. 

As  a  result  every  physician  in  industry  is  a  strong  advocate  of 
some  form  of  health  insurance  which  will  prevent  poverty  from  being 
the  most  powerful  ally  of  disease,  as  it  is  at  present.  These  physicians 
may  differ  widely  on  the  exact  nature  and  methods  of  administration 
of  this  form  of  insurance  but  that  some  form  is  needed  is  harmoniously 
agreed  by  all. 

Practically  all  of  the  great  industrial  countries  of  Europe  have  had 
health  insurance  for  many  years,  as  well  as  insurance  against  accidents. 
The  American  Association  for  Labor  Legislation,  the  American 
Manufacturer's  Association  and  one  or  two  commissions  appointed  by 
state   legislatures    have  made  extensive  studies  in  Europe  of  these 


742  INDUSTRIAL   MEDICINE    AND    SURGERY 

systems  and  much  of  our  proposed  legislation  is  based  upon  their  plans. 
The  country  will  always  be  indebted  to  the  first  named  organization  for 
the  part  it  has  played  in  stimulating  this  great  social  movement.  Many 
different  agencies  in  the  country  have  opposed  the  views  expressed 
by  these  organizations  but  the  discussion  thus  aroused  has  resulted  in  a 
closer  study  of  the  question.  At  the  beginning  of  the  war  at  least 
fifteen  different  commissions  and  associations  in  this  country  were 
scrutinizing  every  proposed  angle  of  health  insurance.  These  com- 
missions were  of  one  accord  in  that  they  would  not  accept  any 
European  plan  in  part  or  in  toto,  but  that  the  system  of  health  insur- 
ance finally  adopted  by  America  must  accomplish  its  purpose  without 
unduly  affecting  the  personal  rights  of  any  individual,  unduly  dis- 
turbing the  economic  conditions  of  the  country  or  placing  an  injustice 
of  any  kind  upon  labor,  capital  or  the  state.  If,  after  a  most  intelli- 
gent study  of  this  question,  proper  legislation  is  passed,  there  will 
inevitably  follow  some  of  the  greatest  social  reforms  our  country  has 
yet  seen.  It  is,  therefore,  worthy  of  comment  that,  instead  of  the 
legislatures  of  the  various  states  hurriedly  passing  proposed  health 
insurance  laws,  many  of  them  have  appointed  commissions  and 
appropriated  large  sums  of  money  for  a  complete  study  of  the  subject 
with  recommendations  as  to  the  proper  form  legislation  should  take. 
Some  of  the  opponents  of  this  movement  are  endeavoring  to  prolong 
these  studies  and  thus  delay  the  necessary  laws.  We  must  not  unduly 
hasten  these  investigations  but  every  man  who  believes  in  health 
insurance  must  give  his  assistance  and  use  his  influence  for  an  adequate 
health  insurance  law  just  as  soon  as  possible. 

Mr.  John  B.  Andrews,  Secretary  of  the  American  Association  for 
Labor .  Legislation,  in  an  address  before  the  National  Conference  of 
Social  Workers  in  1917,  gave  the  following  resume  on  the  progress 
toward  health  insurance: 

"Progress  toward  workmen's  health  insurance  has  probably 
aroused  more  earnest  discussion  in  a  greater  number  of  interested 
groups  than  has  any  other  single  campaign  in  the  whole  field  of  social 
legislation.  Following  as  a  logical  next  step  the  enactment  within 
seven  years  of  workmen's  compensation  laws  in  four-fifths  of  the 
American  states  and  territories- — and  with  America  stigmatized  as 
the  only  important  industrial  nation  of  the  world  without  compulsory 
health  insurance — it  is  natural  that  definite  proposals  for  publicly 
insuring  against  the  wage-earners'  sickness  should  have  excited  ex- 
ceptional comment.  Undoubtedly,  too,  the  method  by  which  the 
legislation  was  presented  had  something  to  do  with  the  spirited 
discussion  of  its  merits — an  educational  effect  of  justly  reputed 
value  in  our  political  democracy. 

"The  definite  health  insurance  program  was  formulated  by  a  special 


HEALTH   INSURANCE  743 

national  committee  whose  members  had  been  most  active  in  consist- 
ently working  for  adequate  standards  in  workmen's  compensation  laws. 
With  a  preliminary  conference  in  Boston  in  December,  1912,  at  the 
annual  meeting  of  the  American  Association  for  Labor  Legislation, 
this  committee  organized  the  First  National  Conference  on  Social 
Insurance,  held  in  Chicago  in  June,  1913.  One  year  later  'tentative 
standards'  were  widely  distributed  for  criticism  and  suggestions  and 
as  a  result  of  numerous  meetings  and  much  correspondence  with 
representatives  of  labor,  employers,  and  physicians,  the  first  tentative 
draft  of  an  act  for  health  insurance  was  published  in  November, 
1915.  Second  and  third  revised  editions  with  explanatory  notes 
have  resulted  in  a  preliminary  distribution  of  more  than  25,000 
copies  while  reprints  in  professional  and  trade  journals  and  in 
pamphlets  represent  an  additional  circulation  of  at  least  double  that 
number.  Every  effort  has  been  made  to  stimulate  helpful  discussion, 
both  sympathetic  and  hostile.  Although  still  in  tentative  form  prob- 
ably no  piece  of  social  legislation  in  this  country  has  had  more 
careful  preliminary  consideration.  The  educational  results  have 
amply  justified  both  the  method  and  the  effort. 

"Principles  of  the  Standard  Bill. — In  brief,  the  standard  health 
insurance  program  is  the  result  of  a  growing  conviction  that  sickness 
is  one  of  the  principal  causes  of  poverty,  that  sickness  is  an  insurable 
risk,  that  existing  agencies  for  meeting  the  problem  are  inadequate  and 
place  upon  those  who  do  insure  against  sickness  an  unjust  and  un- 
necessarily high  burden  and  this  without  fully  utilizing  the  preventive 
value  of  mutually  administered  workmen's  insurance.  Provision  is 
made  for  the  universal  application  of  health  insurance  to  all  workers 
earning  less  than  a  specified  amount  by  requiring  that  while  at  work  a 
few  cents  per  week,  based  upon  and  deducted  from  earnings,  shall  be 
placed  in  a  fund,  under  state  supervision,  to  which  the  employer 
contributes  a  like  amount  and  the  state  one-half  as  much.  The  system 
is  non-contributory  for  workers  receiving  less  than  a  specified  minimum 
wage.  When  incapacitated  by  illness  or  by  accident  not  covered  by 
workmen's  compensation,  the  workman  would  be  entitled  to  receive 
at  the  expense  of  the  fund  adequate  medical,  surgical  and  nursing  care 
and  two-thirds  of  wages  until  able  to  resume  work,  but  not  for  more 
than  twenty-six  weeks'  incapacity  in  any  one  year.  For  fatal  cases  a 
funeral  allowance  of  $100  is  provided  and  for  women  workers  and  for 
the  wives  of  insured  men  provision  is  made  for  maternity  care.  Ad- 
ministration of  this  insurance  recognizes  trade  union  funds,  establish- 
ment funds  and  fraternals  as  approved  societies  but  encourages  the 
formation  of  mutual  local  or  trade  funds  to  be  jointly  conducted  at 
actual  cost.  No  provision  is  made  for  recognizing  profit-making  or 
commercial  insurance  companies. 


744  INDUSTRIAL    MEDICINE    AND    SURGERY 

"Endorsed  by  Official  Commissions.^ — Bills  based  upon  this  standard 
measure  were  introduced  in  three  legislatures  in  1916  and  in  a  dozen 
states  in  1917.  Meanwhile  official  social  insurance  commissions  in 
California  and  Massachusetts  were  investigating  and  early  in  1917 
the  California  commission  announced  that,  in  a  survey  of  the  social 
insurance  field,  it  had  reached  the  unanimous  conclusion  to  center  all 
efforts  upon  health  insurance  as  the  logical  and  most  practical  next 
step  following  workmen's  compensation.  The  commission  concisely 
stated  unanimous  agreement  in  the  following  sentence: 

"In  order  to  meet  the  problems  of  destitution  due  to  sickness,  and  in  order 
to  make  health  insurance  a  valuable  adjunct  to  the  broad  movement  for  the 
conservation  of  public  health,  any  legislation  on  this  subject  should,  in  the  opinion 
of  the  commission,  provide  (a)  for  a  compulsory  system  for  the  conducting  of  the 
insurance  by  non-profit  making  insurance  carriers;  (5)  for  a  thoroughly  adequate 
provision  for  the  care  and  treatment  of  the  sick,  and  (c)  for  contributions  from 
the  insured,  from  industry  and  from  the  state. 

"The  Massachusetts  commissioners  attempted  by  means  of  sub- 
committees to  deal  with  the  whole  field  of  social  insurance  during  the 
brief  half-year  between  legislative  sessions  and  naturally  arrived  at 
conclusions  not  entirely  acceptable  to  all  of  the  members  of  the  com- 
mission. In  endorsing  the  principle  of  health  insurance,  however,  the 
commission  was  unanimous.  A  majority  of  the  members  were  further- 
more in  accord  with  the  main  provisions  of  the  health  insurance  bill 
introduced  this  session  in  the  Massachusetts  legislature,  and  believed 
that  the  system,  to  be  effective,  must  be  compulsory  and  that  the  cost 
should  be  distributed  among  employer,  employee,  and  the  state.  The 
major  report,  submitted  by  the  sub-committee  on  health  insurance, 
was  signed  by  four  commissioners,  including  the  chairman  of  the  com- 
mission. Briefly,  the  report  in  its  recommendations  agrees  in  most 
particulars  with  the  conclusions  reached  independently  on  the  opposite 
coast  by  the  California  commission.  The  Massachusetts  report 
recommends  compulsory,  contributory  workmen's  health  insurance 
legislation,  with  private  stock  companies  operating  for  profit  excluded 
from  the  field.  'The  plan  of  insurance,'  states  this  report,  'most  likely 
in  our  opinion  to  prove  successful  is  one  in  which  the  carriers  are 
mutual  associations  managed  by  employers  and  employees,  equally.' 
Thus  the  Massachusetts  report  agrees  in  this  particular  also  with  the 
legislative  proposal  of  the  American  Association  for  Labor  Legislation. 

"Executive  encouragement  to  the  health  insurance  movement  was 
not  lacking.  Governor  Hiram  W.  Johnson,  m  commending  the  work 
of  the  California  commission,  said  in  his  message  to  the  legislature: 
'  I  believe  in  health  insurance,  and  that  ultimately  it  will  be  established 
in  our  nation,  and  this  within  a  brief  period.'  Governor  Samuel  W. 
McCall  in  his  inaugural  address  urged  the  Massachusetts  legislature  to 


HEALTH    INSURANCE  745 

enact  compulsory  health  insurance,  saying:  'I  am  strongly  of  th(; 
opinion  that  there  is  no  form  of  social  insurance  that  is  more  humane, 
sounder  in  principle,  and  that  would  confer  a  greater  benefit  upon  large 
groups  of  our  population  and  upon  the  commonwealth  as  a  whole  than 
health  insurance.' 

"Eight  States  Making  Investigations. — In  Calif  ornia  it  was  believed 
that  a  peculiar  constitutional  restriction  in  that  state  might  endanger 
the  safety  of  compulsory,  contributory  health  insurance,  and  the  legis- 
lature, therefore,  promptly  passed  through  both  houses  for  the  ratifi- 
cation of  the  people  a  constitutional  amendment  declaring  it  to  be 
'  the  policy  of  the  State  of  California  to  make  special  provision  for  the 
health  and  welfare  of  those  classes  of  persons,  and  their  dependents, 
whose  incomes,  in  the  determination  of  the  legislature,  are  not  sufficient 
to  meet  the  hazards  of  sickness.  The  legislature  may  establish  a  health 
insurance  system,  applicable  to  any  or  all  such  persons,  and  for  the 
financial  support  of  such  system  may  provide  for  contributions,  either 
voluntary  or  compulsory,  from  such  persons,  from  employers,  and  from 
the  state  by  appropriations.' 

"In  order  to  continue  the  work  of  education  and  legislation  in 
California  there  was  appropriated  for  the  expense  of  the  commission 
an  additional  sum  of  $22,500.  In  Massachusetts  where  the  momen- 
tary confusion  which  accompanied  our  nation's  entrance  into  the 
war  gave  a  temporary  setback  to  all  social  legislation  there  was  later 
provided  a  special  recess  commission,  this  time  to  concentrate  on 
health  insurance,  with  the  usual  arrangement  as  to  necessary  expenses. 
In  Ilhnois  and  Pennsylvania  health  insurance  commission  bills  were 
enacted  with  expense  appropriations  of  $20,000  and  $5000,  re- 
spectively. Ohio  created  a  commission  to  study  both  health  insurance 
and  old  age  pensions  and  voted  $25,000  for  the  purpose.  Wisconsin, 
moved  by  a  growing  sentiment  for  health  insurance  legislation,  author- 
ized official  study  of  social  insurance  and  appropriated  $5000. 
Connecticut  embodied  health  insurance  in  an  omnibus  commission 
study  bill,  and  the  New  Jersey  commission  to  inquh'e  into  old  age 
dependency  and  insurance  reached  the  conclusion  that  any  compre- 
hensive plan  for  old  age  relief  should  be  preceded  by  universal  work- 
men's health  insurance.  Thus  in  no  less  than  eight  states  official 
investigation  of  health  insurance  is  under  way. 

"This  rather  remarkable  progress  toward  health  insurance  was  no 
doubt  stimulated  to  a  degree  by  various  official  reports.  Following  a 
two  years'  survey  of  occupational  diseases  under  the  general  direction 
of  Dr.  Emery  R.  Hayhurst,  the  Ohio  State  Board  of  Health  declared 
that  'underlying  the  high  sickness  and  death  rate  prevalent  among 
wage-earners  is  the  industrial  factor,'  that  inadequate  legislation  and 
inefficient  inspection  are  due  to  lack  of  interested  co-operation  from 


746  INDUSTRIAL   MEDICINE    AND    SURGERY 

employer  and  employee,  and  that  'until  some  direct  incentive  to 
improve  factory  sanitation  is  offered  little  real  progress  can  be  hoped 
for.  The  cash  value  set  upon  health  by  health  insurance  promises 
the  needed  stimulus.'  In  harmony  with  this  conclusion  was  a 
special  bulletin  on  health  insurance  issued  by  the  United  States  Public 
Health  Service,  in  which  a  compulsory,  contributory  system  mutually 
managed  and  without  opportunity  for  profit-making  was  strongly 
recommended.  Similar  to  this  in  effect  was  the  conclusion  of  the 
United  States  Commission  on  Industrial  Relations.  Finally  the 
United  States  Commissioner  of  Labor  Statistics  in  a  brilhant  paper 
before  the  International  Association  of  Industrial  Accident  Boards  and 
Commissions,  of  which  he  is  the  distinguished  secretary,  is  strongly 
on  record  as  favoring  '  health  insurance — universal,  compulsory,  state 
health  insurance — true  social  insurance.' 

"A  Rapidly  Increasing  Public  Demand. — Scarcely  less  important 
than  the  official  steps  noted  above  have  been  the  many  endorsements 
of  health  insurance  by  private  organizations.  Closely  following  the 
tentative  standards  drawn  up  by  the  Association  for  Labor  Legislation 
have  come  vigorous  expressions  of  approval  from  numerous  labor, 
civic  and  medical  societies  and  from  forward  looking  employers. 

''In  addition  to  local  trade  unions  and  city  central  organizations 
throughout  the  country  more  than  a  dozen  of  the  most  influential 
state  federations  of  labor  and  national  and  international  trade  unions 
have  adopted  resolutions  favoring  the  principle  of  health  insurance  and 
have  left  no  doubt  as  to  their  stand  in  reference  to  commercial  in- 
surance participation.  Opposition  to  such  profiteering  is  thus 
pointedly  expressed  in  the  resolution  adopted  last  November  by  the 
American  Federation  of  Labor : 

"Resolved:  That  the  American  Federation  of  Labor  in  Thirty-sixth  Annual 
Convention  assembled,  declared  against  private  insurance,  or  insurance  for  profit, 
as  it  may  apply  to  industrial,  social  or  health  insurance. 

"Among  a  large  number  of  outstanding  leaders  in  the  American 
labor  movement  who  are  on  record  in  favor  of  health  insurance  are 
John  Mitchell  and  James  M.  Lynch,  who  are  now  members  of  the 
New  York  Industrial  Commission;  James  Duncan,  the  president  of 
the  Granite  Cutters'  International  Union  and  First  Vice-president  of  the 
American  Federation  of  Labor ;  and  William  Green,  Eighth  Vice-presi- 
ent  of  the  American  Federation  of  Labor  and  Secretary-treasurer  of 
the  United  Mine  Workers,  the  largest  trade  union  in  America.  The 
National  Women's  Trade  Union  League  at  its  convention  in  June, 
1917,  went  strongly  on  record  for  health  insurance,  including  maternity 
care,  for  the  millions  of  women  workers.  In  harmony  with  this 
sentiment  is  the  following  conclusion:     'A  governmental  system  of 


HEALTH    INSURANCE  747 

sickness  insurance  is  preferable  because:  More  democratic;  the 
benefits  would  be  regarded  as  rights,  not  charity.  Compulsory 
features,  obnoxious  under  private  insurance,  would  be  no  longer 
objectionable  .  .  .  European  experience  has  proved  the  superiority 
of  government  systems  to  private  insurance.' — Final  Report,  U.  S. 
Commission  on  Industrial  Relations;  signed,  among  others,  by  John 
B.  Lennon,  Treasurer,  American  Federation  of  Labor;  James  O'Connell, 
Second  Vice-president,  American  Federation  of  Labor;  Austin  B. 
Garretson,  President,  Order  of  Railroad  Conductors. 

"Organizations  of  employers  have  been  less  ready  to  publicly  go  on 
record  for  a  system  of  health  insurance  which  is  bound  to  cost  them 
a  considerable  initial  outlay  no  matter  what  returns  they  later  receive 
through  the  increased  efficiency  and  contentment  of  a  healthy  working 
force.  But  even  here,  as  in  the  case  of  the  Boston  Chamber  of  Com- 
merce, desire  has  been  expressed  to  have  the  subject  studied,  and  the 
best  informed  employers  have  not  hesitated  to  say  that  they  regard  the 
coming  of  health  insurance  as  inevitable.  Ferdinand  C.  Schwedtman 
who,  as  chairman  of  an  important  committee  of  the  National  Association 
of  Manufacturers  made  a  study  of  European  experience  with  social 
insurance,  in  a  preHminary  report  in  1914,  said:  'I  give  it  as  my  opinion 
that  sickness  insurance  of  some  kind,  with  compulsory  contributions 
on  the  part  of  the  employers,  will  be  enacted  into  law  by  many  states 
of  the  Union  within  the  next  five  years,  and  that  now  is  the  time 
to  go  into  this  subject  thoroughly.'  The  National  Association  of 
Manufacturers  committee,  now  under  different  leadership,  has  not 
been  able  to  reach  and  maintain  this  open-minded  attitude.  By 
way  of  comparison  it  is  interesting  to  note  the  following  conclusion 
reached  in  1916  by  the  committee  on  public  relations  of  the  American 
Electric  Railway  Association : 

"The  benefits  of  health  insurance  can  only  be  made  wide-spread  by  making 
insurance  compulsory.  Compulsory  insurance  can  be  best  introduced  by  the 
employer  making  a  substantial  contribution  toward  the  cost  of  insurance,  con- 
sidering such  contribution  as  a  part  of  the  wage  payment  and  an  element  in  the 
cost  of  production. 

"Just  as  the  compensation  of  the  machine  which  has  outworn  its  usefulness 
is  chargeable  to  the  productive  process,  so  it  is  now  considered  that  the  cost  of 
industrial  accidents  to  employees  is  properly  borne  by  the  industry.  A  somewhat 
similar  philosophy  underlies  the  demand  for  health  insurance  legislation  now  being 
concurrently  urged  in  several  states  of  the  Union. 

"A  middle  course  theory  reconciles  this  recent  tendency  as  not  out  of  accord 
with  the  ideals  of  individualism.  It  recognizes  accidents,  sickness,  and  death 
as  capital  hazards  confronting  each  individual.  Adequate  provision  for  them  by 
the  individual  is  frequently  impossible,  even  with  great  sacrifice  and  foresight. 
.  .  .  Yet,  by  co-operative  action,  the  cost  of  such  capital  hazards  may  be  shared 
and  borne  with  slight  difficulty.  This  assists  rather  than  interferes  with  the 
maximum  individual  progress. 


748  INDUSTRIAL    MEDICINE    AND    SURGERY 

''Moreover,  the  American  Chamber  of  Commerce  in  Berlin  which 
has  had  an  opportunity  to  see  health  insurance  in  operation  under 
government  auspices  declared  that, 

"Compulsory  workmen's  insurance  has  raised  the  working  classes  in  Germany 
in  respect  to  health,,  economy,  and  standing  in  the  community,  and  it  is  clear  that, 
with  their  aid  only,  Germany  has  maintained  her  position  in  the  markets  of  the 
world.  And  furthermore,  hundreds  of  thousands,  now  fighting  on  the  field  of 
battle,  may  trace  their  health  and  capacity  to  the  timely  and  proper  treatment 
received  with  the  aid  of  sickness  insurance. 

"Medical  Profession  Deeply  Interested. — The  medical  profession 
which  is  always  profoundly  affected  by  any  thorough-going  system  of 
health  insurance  has  perhaps  taken  a  more  active  part  in  the  movement 
in  America  than  has  either  of  the  other  two  directly  affected  groups 
already  mentioned.  This  alertness  is  perhaps  due  in  large  part  to  the 
manner  in  which  the  legislation  was  presented.  Mindful  of  British 
experience  where  the  physicians  threatened  to  go  on  strike  against  the 
Lloyd  George  act  (fearing  lest  their  incomes  be  reduced  but  learning 
later  in  actual  practice  under  the  law  that  their  incomes  were  measur- 
ably increased)  the  original  drafters  of  health  insurance  bills  in  this 
country  left  the  medical  sections  in  merest  outline  and  urged  the 
doctors  to  suggest  provisions  acceptable  to  the  medical  profession. 
The  American  Medical  Association  immediately  accepted  the  invita- 
tion in  good  spirit  and  appointed  a  committee  of  which  Dr.  Alexander 
Lambert  is  chairman  and  Dr.  I.  M.  Rubinow  executive  secretary  to 
investigate  and  report.  Several  valuable  pamphlets  have  already 
appeared  as  a  result  of  this  expert  committee's  work,  and  at  the  annual 
convention  of  the  American  Medical  Association  in  June,  1917,  the 
House  of  Delegates  adopted  a  resolution  encouraging  further  work 
on  the  subject  and  instructing  its  Council  on  Health  and  Public 
Instruction  to  co-operate  when  possible  'in  the  molding  of  these  laws 
that  the  health  of  the  community  may  be  properly  safeguarded  and 
the  interests  of  the  medical  profession  protected.'  The  resolution  also 
outlined  four  legislative  demands,  the  greater  part  of  which  are 
specifically  met  in  the  standard  bill,  namely,  '.  .  .  insist  that  such 
legislation  shall  provide  for  freedom  of  choice  of  physician  by  the 
insured;  payment  of  the  physician  in  proportion  to  the  amount  of 
work  done;  the  separation  of  the  functions  of  medical  official  super- 
vision from  the  function  of  daily  care  of  the  sick,  and  adequate 
representation  of  the  medical  profession '  on  the  appropriate  admin- 
istrative bodies.' 

"Such  sincere  opposition  as  has  come  from  physicians,  and  there 
is  not  a  little  of  it,  can  be  traced  in  very  many  instances  to  dissatisfac- 
tion with  medical  arrangements  under  workmen's  compensation 
laws  which  in  most  states  were  enacted  without  the  aid  or  special 


HEALTH    INSURANCE  749 

knowledge  of  the  medical  profession.  There  is,  fortunately,  ample 
evidence  that  medical  men  will  not  be  caught  napping  when  health 
insurance  is  enacted,  and  no  less  a  leader  than  Surgeon  General  Rupert 
Blue  in  his  address  as  president  to  the  American  Medical  Association 
has  declared:  'Health  insurance  is  the  next  great  step  in  social 
legislation.' 

"Selfish  Opposition  by  Private  Insurance  Companies. — Although 
the  exclusion  of  the  commercial  insurance  element  from  profiteering 
in  social  health  insurance  follows  the  tested  experience  of  other 
countries,  and  is  in  line  with  an  unmistakable  American  tendency 
as  a  result  of  practical  experience  here  with  workmen's  compensation 
legislation,  every  effort  to  exclude  such  profiteering  in  these  mis- 
fortunes of  the  wage-earners  is  met  with  vigorous  and  characteristic- 
ally selfish  opposition.  It  is  not  too  much  to  say  that  nine-tenths 
of  the  opposition  to  social  health  insurance  comes  directly  from  men 
who  are  in  the  employ  of  private  insurance  companies.  Any  one 
familiar  with  the  private  insurance  propaganda  of  vilification  against 
the  public  method  of  conducting  workmen's  compensation  will, 
of  course,  not  be  misled  by  similar  efforts  to  confuse  the  public  re- 
garding health  insurance. 

"War  Conditions  Emphasize  Need.^ — Despite  efforts  of  an  interested 
opposition  to  throw  sand  in  legislators'  eyes  there  is  no  doubt  about 
the  growing  conviction  of  the  public  that  private  insurance  has  proven 
itself  woefully  inadequate  to  meet  the  sickness  problem  and  as  a 
commercial  venture  places  an  unnecessarily  heavy  burden  upon  those 
least  able  to  bear  it.  This  conviction  was  already  beginning  to 
crystallize  into  legislation  in  time  of  peace.  In  time  of  war  the  needs 
of  our  industrial  army,  which  constitutes  our  first  line  of  defense, 
very  greatly  accentuate  the  urgency  of  a  comprehensive  program  for  the 
conservation  of  our  human  resources.  As  men  are  taken  by  war  from 
shop  and  factory,  those  remaining  must  be  kept  fit  to  meet  the  in- 
creased demand  for  output.  And  as  women  enter  industry  in  rapidly 
increasing  numbers,  the  need  becomes  even  more  pressing  for  the 
protection  afforded  by  universal  health  insurance,  including  maternity 
care. 

"Existing  protective  standards  for  labor  must  be  upheld  in  the 
interest  of  national  effectiveness.  But  in  addition  to  that  we  must 
make  provisions  for  increasing  still  further  the  nation's  productive 
power  and  the  wellbeing  of  its  workers.  Healthy  wage-earners  are 
the  foundation  of  national  strength  both  in  peace  and  war. 

"UnfamiHar  work  and  intense  effort  due  to  industrial  shifting  re- 
quired by  war  will  increase  the  toll  of  sickness  among  wage-earners, 
particularly  women,  as  it  has  in  Europe.  Workmen's  compensation 
provides   the  stimulus  for  prevention  of  accidents.     Under  universal 


750  INDUSTRIAL    MEDICINE    AND    SURGERY 

health  insurance  there  would  be  similar  efforts  to  prevent  sickness. 
It  is  in  the  public  interest  to  provide  the  machinery  by  which  preven- 
tive measures  against  disease  will  be  stimulated  and  adequate  medical 
attention  and  cash  benefits  provided  to  tide  the  workers  over  sickness 
periods  without  distress  and  destitution.  Health  insurance  is  social 
justice.  The  responsibility  for  sickness  is  shared  by  industry,  the 
worker,  and  the  state,  and  all  three  will  share  in  the  benefits  of  public 
health." 

Group  insurance,  that  is,  the  plan  of  insuring  a  body  of  persons 
working  under  the  same  general  conditions  and  presenting  an  average 
of  normal  health  and  medium  age,  is  a  plan  conceived  some  six  or 
seven  years  ago  and  which  has  been  adopted  by  a  number  of  industries 
of  the  country.  Group  insurance  is  not  offered  as  a  substitution  for 
health  insurance,  as  it  deals  chiefly  with  the  problems  of  life  insurance. 
It  is  purely  a  commercial  plan,  but  based  upon  the  principle  of  the 
employer  giving  more  to  his  employees  and,  therefore,  getting  more 
from  them.  In  practically  every  concern  where  group  insurance  has 
been  introduced  the  relationship  between  employer  and  employee  has 
improved,  due  to  the  reawakened  interest  of  the  one  in  the  other. 

At  times  the  advocates  of  health  insurance  have  condemned  the 
group  insurance  plan  and  the  advocates  of  the  latter  have  fought  the 
former  plan.  It  would  seem  that  there  is  good  in  both  and  that  both 
ideas  should  be  included  in  the  final  enactment  of  legislation  on  this 
important  subject. 

Health  insurance  will  give  the  necessary  relief  to  the  working 
man  or  his  family  during  the  period  of  disability  but  it  will  not  pro- 
vide sufficiently  for  the  relief  of  the  family  after  the  wage-earner's 
death.  Group  insurance,  on  the  other  hand,  gives  a  nest  egg  to 
the  dependents  during  that  period  of  readjustment  following  the 
loss  of  their  provider  but  does  not  afi^ord  relief  during  his  term  of 
sickness.  Group  insurance  combined  with  employees  compensation 
for  accidents  has  already  demonstrated  the  need  of  some  form  of 
life  insurance  combined  with  health  insurance.  And  further,  death  is 
not  always  the  agency  which  deprives  the  family  of  their  support, 
but  premature  break-downs,  old  age  and  even  non-employment  have 
contributed  largely  to  destitution.  Thus  pension,  especially  old  age 
pension,  is  another  form  of  insurance  which  is  as  essential  as  health  and 
and  life  insurance. 

While  these  various  insurance  plans  are  being  thrashed  out  it 
behooves  all  commissions  studying  the  problems  to  make  strong 
recommendations  for  improved  compensation  laws  in  case  of  accidents, 
and  especially  a  standardization  of  the  existing  compensation  acts. 

Mr.  Whiting  Williams  has  pointed  out  the  need  of  insuring  the 
workers  of  the  country  thusly: 


HEALTH    INSURANCE  751 

'"Why  do  the  charities  need  money  when  we  can't  get  enough  men 
to  run  our  factories?' 

"This  question  came  from  every  side  to  the  writer  last  year  when 
secretary  of  the  Federation  for  Charity  and  Philanthropy.  Here  is 
the  answer: 

"One  of  the  large  New  York  charities  said  not  long  ago  that  more 
than  nine-tenths  of  all  their  cases  were  caused  directly  or  indirectly  by 
sickness,  including  death  of  the  bread-winner.  An  investigation  of 
some  five  thousand  families  had  earlier  shown  that  one-third  were  of 
the  'widow  type,'  the  father  dead  or  permanently  disabled.  Because 
widows  and  fatherless  children  need  'permanent,  liberal  and  regular' 
relief  also,  such  families  require  more  than  one-third  of  the  money 
secured. 

"What  had  these  fathers  been  doing?  Most  of  them  had  been 
factory  workers — and  it  must  be  remembered  that  the  presence  of 
fatherless  children  always  denotes  that  the  fathers  were  cut  down  in 
their  prime.  In  Ohio  and  a  number  of  other  states  industry  makes 
some  amend  by  money  awards,  where  death  occurred  as  the  direct 
result  of  a  factory  mishap.  But  this  cares  for  only  about  six  or  seven 
per  cent,  of  industry's  widows  and  orphans.  The  others,  for  the  most 
part,  make  a  burden  upon  their  none  too  prosperous  friends,  or  compel 
harassed  charity  officials  to  explain  why  contributions  are  needed  in 
so-called  'good  times.' 

"The  head  of  the  city's  Jewish  Federated  Charities  has  pointed  out 
that  there  is  no  reason  in  the  world  why  industry  should  not  pay  for 
its  fearful  wear  and  tear  on  the  human  machine,  just  as  it  'charges  up' 
the  cost  of  the  steel  machines  it  finds  it  necessary  to  'scrap'  from  time 
to  time. 

"The  new  group  insurance  is  a  way  of  doing  this,  with  the  additional 
advantage  that  its  cost  is  largely  offset  by  the  savings  it  effects.  With- 
out increasing  the  price  of  the  manufactured  product  and  hence  the 
cost  of  living,  this  six-year-old  form  of  insurance  utilizes  team-work  to 
relieve  industry's  workers  from  the  necessity  of  competing  with  the 
war's  victims  for  a  share  of  charity's  dole,  and  at  the  same  time 
operates  to  increas  the  productive  effectiveness  of  the  factory  in  its 
indispensable  support  of  the  firing-line." 

The  group  insurance  plan  referred  to  by  Mr.  WilHams  is  excel- 
lently described  by  Mr.  W.  A.  Day,  President  of  the  Equitable  Life 
Insurance  Society  of  the  United  States,  who  says : 

"Group  insurance  is  the  name  given  to  a  comparatively  new  de- 
velopment in  American  Hfe  insurance.  Its  object  is  to  enable  the 
employer,  who  has  under  him  a  large  number  of  workers,  to  increase 
the  efficiency  and  stimulate  the  loyalty  of  these  workers  by  rendering 
them  a  genuine  service;  the  aim  and  the  result  of  which  is  to  strengthen 


752  INDUSTRIAL   MEDICINE    AND    SURGERY 

mutual  good  will  and  make  the  business  relations  between  employer 
and  employee  closer  and  more  permanent. 

"The  employer  accomplishes  this  by  giving  to  each  employee  a 
moderate  amount  of  life  insurance  for  the  protection  of  his  dependent 
family. 

"Every  life  earning  a  pay  check  has  a  definite  insurable  value.  The 
ultimate  aim  of  group  insurance  is  to  cover  these  values.  It  is  a  plan 
for  insurance  at  its  source  under  which  the  employer  provides  the  life 
insurance  to  protect  the  pay  check.  It  brings  life  insurance  to  a  large 
number  of  unprotected  families  who,  but  for  this  plan,  would  continue 
unprotected. 

"Group  insurance  is  based  on  the  principle  of  co-operation  between 
the  employer  and  the  employee,  for  the  benefit  of  both  alike.  The 
insurance  is  at  the  expense  of  the  employer  only  in  the  sense  that  the 
employer  pays  the  premium  cost  of  the  same.  Experience  indicates 
that  increased  efficiency  on  the  part  of  the  employee  in  response  to 
constructive  efforts  in  his  behalf  fully  justifies  the  cost  of  the  insurance. 
Group  insurance  may  be  viewed  as  a  practical  application  of  social 
insurance  principles  in  strict  accord  without  American  ideals  of  in- 
dividualism. In  my  judgment  the  group  insurance  principle  by  means 
of  which  the  employer  assists  the  employee  in  protecting  himseK 
against  distress  in  various  relations  suggests  a  solution  of  many  of  the 
problems  now  involved  in  industrial  relationship .... 

"After  the  work  at  fair  wage  comes  the  protection  of  that  wage  from 
loss.  Such  loss  may  be  due  to:  First,  death;  second,  disability; 
third,  superannuation. 

"The  measures  effective  to  prevent  these  forms  of  distress  are,  in 
order:  life  insurance  protection  against  the  loss  of  the  wage  through 
death;  health  and  accident  insurance  protection  against  the  loss  of  the 
wage  through  temporary  or  permanent  disability;  pensions  or  saving 
system  against  the  loss  of  the  wage  through  inability  to  work  because 
of  old  age  incapacity. 

"So  far  as  these  plans  or  any  of  them  can  be  made  to  serve  on  the 
theory  of  justifying  such  additional  expenditures  by  the  employer 
because  of  additional  efforts  on  the  part  of  the  employee,  the  plans  are 
economically  sound. 

"Group  Ufe  insurance  approaches  the  labor  problem  by  recognizing 
that  irrespective  of  the  size  of  the  pay  envelope  large  classes  of  people 
will  remain  who  through  thoughtlessness  or  lack  of  urging,  or  physical 
inability,  do  not  themselves  provide  life  insurance  for  the  protection 
of  their  dependents.  A  careful  study  of  our  claim  figures  indicates 
that  perhaps  as  high  as  40  per  cent,  of  the  wage-earners  have  no  life 
insurance.  Life  insurance  is  only  purchased  because  of  persuasion  by 
an  agent.     Unless  the  agent  has  the  opportunity  to  point  out  the 


HEALTH    INSURANCE  753 

necessity  for  life  insurance  to  an  individual,  this  individual  views  his 
obligation  in  the  abstract  and  fails  to  make  unsohcited  application  for 
insurance.  Then  again  there  is  a  certain  percentage  of  those  applying 
for  life  insurance  who  do  not  measure  up  to  the  required  standards  of 
insurability.  If  such  men  applied  individually  for  insurance  they 
would  be  rejected. 

"The  group  insurance  plan  contemplates  the  inclusion  of  the  weaker 
lives  by  supporting  them  by  the  larger  percentage  of  the  stronger  lives. 
Hence,  insurable  classes  are  obtained  by  having  the  insurance  embrace 
all  the  employees  of  any  single  employer,  who  has  proper  regard  for  the 
selection  of  his  employees  and  for  surrounding  them  with  safeguards  to 
health  and  limb.  Thus  the  employee  may  be  insured  according  to  the 
rating  for  age,  occupation  and  industry  without  reference  to  the  in- 
dividual insurability  of  any  particular  employee.  By  this  means,  the 
group  plan  becomes  universal  throughout  the  little  dominion  of  one 
employer. 

"A  group  contract  is  made  with  this  employer,  setting  forth  the 
terms,  conditions,  and  rates  under  which  the  insurance  will  be  continued. 
Each  employee  is  given  a  supplementary  insurance  certificate  written 
in  the  name  of  the  employee,  stating  the  amount  of  the  insurance,  and 
giving  the  name  of  the  beneficiary  designated  by  the  employee  to  re- 
ceive the  insurance  if  death  occurs  during  continuance  in  the  employ. 

"This  means  the  elimination  in  that  particular  establishment  of  any 
necessity  for  '  passing  the  hat '  among  fellow  employees,  to  care  for  the 
survivor  of  some  employee  who  has  died  unprotected.  It  means  that 
a  certain  sum  of  insurance  will  be  available  in  the  home  on  the  death  of 
a  worker  so  covered,  to  supply  the  money  immediately  necessary  for 
the  funeral,  and  enough  more  to  serve  as  a  substitute  for  the  wage  check 
during  a  reasonable  period  in  which  to  readjust  the  affairs  of  the  familjj 
to  the  new  conditions. 

"The  amount  of  the  insurance  is  usually  based  on  one  year's  wage 
or  salary,  with  a  maximum  limit  of  $3000  to  those  receiving  more  than 
that  sum.  In  other  cases  the  amount  of  the  insurance  is  some  flat  sum 
such  as  $1000  to  each.  A  third  plan  is  that  of  graded  insurance  such  as 
$500  or  $1000  to  be  increased  by  $100  insurance  per  year  for  each 
additional  year  of  service  up  to  a  fixed  maximum.  These  plans  are 
variously  adapted  to  fit  the  views  of  an  employer  as  to  the  needs  of  his 
employees,  and  the  ability  of  his  business  to  provide  the  premium 
costs  of  group  insurance  to  fill  these  needs. 

"That  some  life  insurance  is  a  vital  need  of  the  worker^  to  protect 
his  dependents,  is  abundantly  testified  to  by  statements  from  em- 
ployees and  from  their  beneficiaries.  One  large  automobile  company 
earring  group  insurance  has  kept  close  record  of  the  conditions  in  the 
homes  to  which  these  group  policies  were  paid. 

48 


754  INDUSTRIAL   MEDICINE    AND    SURGERY 

"Out  of  the  first  fifty  claims  that  were  paid,  it  was  reported  that  there 
had  been  only  one  case  in  which  the  claim  money  was  not  urgently 
needed  to  prevent  immediate  distress.  In  the  one  case  which  was  an 
exception  the  money  was  used  to  advantage  in  paying  off  a  mortgage 
on  the  home.  Another  large  employer  studied  the  effect  of  the  claim 
moneys  in  over  one  hundred  homes  with  practically  the  same  result. 

"In  many  of  the  cases  in  which  those  claims  were  paid,  the  employees 
were  highly  skilled,  commanding  relatively  large  pay.  Conditions 
were  found  to  be  much  the  same  among  the  highly  skilled  and  among 
the  lower  grades  of  labor,  each  class  living  up  to  its  full  income  and 
apparently  not  finding  a  place  in  their  budget  for  a  proper  amount  of 
life  insurance. 

"Time  will  not  permit  me  to  reproduce  statements  from  individual 
beneficiaries,  but  the  following  which  was  sent  from  the  sales  manager 
of  a  large  oil  company  to  the  insurance  company  in  reference  to  a 
group  claim  illustrates  the  good  which  group  insurance  does.  This 
letter  is  in  part  as  follows: 

"  'The  case  of  Mrs.  .  .  .  and  her  two  daughters  is  the  most 
deplorable  one  that  the  writer  has  ever  come  in  contact  with.  All 
three  of  them  are  in  the  last  stages  of  consumption,  with  not  a  penny 
in  the  house,  and  the  $1000  I  handed  them  was  really  the  most  valu- 
able sum  of  money  I  believe  that  ever  went  into  the  State  of  Oregon.' 

"Group  insurance  is  not  a  substitute  for  individual  insurance.  It 
simply  supplements  it.  It  is  meant  to  provide  some  insurance  to  those 
not  otherwise  protected  by  it,  and  to  be  a  substantial  addition  to  the 
individual  insurance  which  all  are  encouraged  to  provide  for  them- 
selves. The  plan  has  been  found  to  work  best  only  as  it  is  operated 
on  an  inclusive  basis;  namely,  to  include  everybody  employed,  or  all 
those  in  the  class  for  whose  benefit  insurance  is  desired. 

"Any  attempt  to  leave  the  choice  with  the  employee  whether  he 
should  secure  this  protection  or  not,  defeats  in  some  degree  at  least 
the  object  of  the  insurance  in  its  attempt  to  be  universal  throughout 
one  group.  For  this  reason  it  has  not  been  found  satisfactory  to  have 
the  employees  pay  for  the  insurance  either  in  whole  or  in  part.  Any 
proposal  for  payment  from  the  employees  entails  the  refusal  of  the 
insurance  by  some  employees,  which  destroys  in  the  first  place  the 
universality  of  the  protection  and  in  the  second  place  impairs  the 
averages  requisite  in  an  insurance  transaction,  because  those  who 
would  stay  out  would  be  as  a  rule  the  stronger  lives  not  feeling  the 
immediate  need  of  the  insurance.   .    .    . 

"It  has  been  urged  at  times  that  group  insurance  might  be  used  to 
keep  down  wages  or  to  keep  men  from  freedom  of  action  in  changing 
their  employment.  This  is  an  erroneous  conclusion.  Any  effort  to 
use  group  insurance  in  this  direction  would  defeat  its  aims  and  make 


HEALTH   INSURANCE  755 

the  expenditure  an  utterly  wasteful  one,  because  it  would  fail  to  improve 
the  industrial  relationship  on  the  basis  of  getting  more  by  giving 
more. 

"One  employer,  already  quoted,  goes  further  than  the  mere  subject 
of  group  life  insurance  by  including  in  his  establishment  other  forms 
of  protection  for  the  employee,  and  states : 

"'I  have  always  believed  that  the  great  problem  of  the  employees' 
unrest  must  be  met  more  by  the  voluntary  act  of  employers  in  remov- 
ing causes  of  unrest  than  through  the  compulsion  of  legislation,  and 
that  it  would  create  a  far  more  beneficial  result  in  the  attitude  of  labor 
toward  capital  if  employers  generally  should  extend  these  benefits 
voluntarily  without  waiting  for  compulsory  legislation.' 

''It  is  interesting  to  note  how  closely  this  reference  is  related  to  the 
whole  subject  of  social  insurance.  It  is  also  interesting  to  note  that 
this  employer  now  providing  voluntarily  for  his  employees'  group  life 
insurance  and  also  group  disability  insurance  in  larger  ways  than  have 
been  proposed  in  any  system  of  compulsory  social  insurance,  comes  to 
the  conclusion  that  the  distress  of  the  employee  must  be  met,  and  that 
the  only  alternatives  are  either  for  the  employer  to  relieve  this  distress 
voluntarily,  or  for  the  state  to  compel  him  to  do  so.   .    .    , 

"The  social  service  of  group  insurance  is  self-evident  and  it  is  being 
rapidly  extended.  It  is  also  clear  that  social  insurance  would  be  but  a 
minor  application  of  relief  principles  which  are  now  advocated  and  are 
achieving  increasing  vogue  through  the  work  of  group  insurance.  Far 
from  competing  with  such  principles  social  insurance  would  probably 
stimulate  the  further  application  of  group  insurance.  It  may  be 
said  that  the  adoption  of  Workmen's  Compensation  Insurance  was  the 
'most  important  single  item  in  opening  up  the  field  for  group  Ufe  in- 
surance. The  workmen's  compensation  laws  have  done  more  than 
stimulate  group  life  insurance.  These  laws  have  also  brought  into 
being  group  health  and  accident  insurance  supplementing  the  com- 
pensation laws  by  voluntarily  providing  compensation  benefits  over 
hours  not  covered  by  these  laws  and  otherwise  extending  benefits  to 
classes  of  salary  workers  excluded  entirely  from  compensation  laws. 

"It  is  also  important  to  note  that  group  insurance  has  stimulated  the 
study  of  the  subject  of  old  age  pensions  by  institutions  not  yet  granting 
pensions,  and  has  had  a  strong  influence  in  effecting  improvements  in 
existing  pension  systems.  The  conditions  of  many  pension  funds 
and  pension  systems  foreshadows  future  disappointment  and  distress. 
To  find  a  pension  fund  well  planned,  well  managed  and  actuarially  sol- 
vent is  the  exception  rather  than  the  rule.  In  the  past  the  advice  and 
services  which  the  insurance  companies  are  able  to  render,  have 
not  been  utilized  to  any  large  extent  in  perfecting  the  pension  systems 
adopted  by  our  large  establishments,  associations  of  school  teachers, 


756  INDUSTRIAL   MEDICINE    AND    SURGERY 

public  servants  of  various  kinds,  and  even  foundations  organized  for 
pension  philanthropies.  The  pension  systems  operated  in  this  country- 
are  almost  all  actuarially  insolvent,  or  in  the  way  to  become  so 
unless  radically  readjusted.  Independent  of  the  financiering  of  the 
pension  the  plan  under  which  these  pensions  have  been  organized  and 
granted  has  not  always  been  one  that  commends  itself  for  justice,  sim- 
plicity and  the  complete  protection  of  the  pensioner.  Group  insurance 
has  done  much  to  call  attention  to  the  pension  subject  as  a  related 
provision  for  protecting  the  employee,  and  has  placed  the  equipment 
of  experts  at  the  disposal  of  those  concerned. 

'  'Group  insurance  is  no  longer  an  experiment.  It  is  an  accomplished 
fact.  It  is  carrying  to  the  employer  a  sound  principle  and  the  convic- 
tion that  he  can,  with  advantage  to  himself,  to  the  employee,  and  to 
humanity,  co-operate  better  to  protect  the  worker  in  ways  which 
bring  returns  commensurate  to  both  and  to  society  at  large." 

Some  of  the  best  principles  thus  far  suggested,  not  only  as  a  basis 
for  health  insurance,  but  for  our  medical  and  surgical  work  and  other 
movements  looking  toward  the  welfare  of  employees,  are  contained 
in  a  paper  entitled  "Human  Relations  in  Industry"  by  Mr.  Whiting 
Williams.  This  article  can  be  found  in  the  transactions  of  the 
National  Safety  Congress  for  1917,  and  should  be  read  by  every 
physician  in  industry. 

At  the  present  time  the  National  Industrial  Conference  Board  is 
making  an  extensive  study  of  occupational  and  accident  hazards  in 
all  industries,  the  industrial  sanitation  and  accident  prevention  plans 
introduced  to  combat  these  hazards  and  the  results  of  medical  and 
surgical  work  being  carried  on  in  industry,  with  a  view  to  stimulating 
legislation  along  the  lines  of  standardized  prevention  of  sickness  and 
accidents.  They  feel  that  eight  or  ten  millions  of  dollars  spent  in 
prevention  would  accomplish  far  greater  results  than  ten  times  those 
amounts  expended  immediately  in  health  insurance.  They  argue  that 
health  insurance  is  the  cart  which  is  being  placed  before  the  horse 
and  that  universal  prevention  at  this  time  is  far  more  important  than 
universal  relief  measures  after  the  damage  is  done.  Every  physician 
in  industry  throughout  the  country  will  have  the  opportunity  of 
assisting  this  association  in  its  investigations  and,  as  their  principles 
are  quite  in  accord  with  the  spirit  of  prevention,  every  facility  for 
the  most  complete  deductions  should  be  given  them.  The  entire 
industrial  force  of  the  country  is  everlastingly  in  debt  to  this  National 
Industrial  Conference  Board  for  the  constructive  measures  they  have 
introduced  into  our  industrial  development  during  the  last  five  years. 
Their  present  investigation  should  have  great  weight  with  all  state 
legislatures  contemplating  the  enactment  of  health  insurance  laws. 


HEALTH    INSURANCE  757 

From  a  study  of  the  various  European  plans  of  health  insurance, 
old  age  pensions,  life  insurance  and  other  forms  of  insurance  and  from  a 
study  of  the  various  plans  for  similar  arrangements  in  this  country 
advocated  by  the  different  governmental  and  civilian  agencies  one 
is  convinced  that  the  great  desire  of  all  civilized  governments  is  to 
improve  the  health  and  thereby  the  economic  conditions  of  their 
working  people.  Unfortunately  some  of  the  systems  in  vogue  in 
other  countries  have  been  too  paternalistic  or  have  wrought  too  great  a 
hardship  on  industry,  or  have  tended  to  stimulate  malingering,  or 
robbed  the  medical  profession  of  their  inalienable  rights,  or  have 
stimulated  political  manipulation.  These  mistakes  give  excellent 
grounds  for  criticism  on  the  part  of  labor,  or  of  capital,  or  of  the 
medical  profession,  or  of  other  groups  of  people  whenever  health 
insurance  legislation  is  proposed  in  any  state. 

Nevertheless,  all  of  these  various  groups  agree  that  some  form  of 
universal  insurance  is  needed.  The  United  States  is  used  to  thinking 
in  big  terms  and  mammoth  propositions  have  always  appealed  to  our 
people.  Since  we  have  entered  the  war  we  have  become  accustomed 
to  talking  in  billions,  to  see  the  Federal  government  assume  control  of 
our  great  industries,  to  see  labor  organized  as  never  before  for  the 
greatest  possible  production,  to  witness  the  food  supply  of  the  country 
controlled  and  conserved  and  to  see  the  medical  profession  organized 
into  a  gigantic  machine  for  the  protection  of  our  armies.  Having 
these  examples  before  us  we  should  realize  that  this  is  the  psychological 
time  to  put  across  the  most  compreherisive  scheme  for  the  betterment 
of  the  health  and  the  economic  conditions,  not  only  of  the  working 
people  but  of  our  entire  population. 

With  this  in  mind,  such  a  program  should  include: 

First,  the  greatest  freedom  in  the  industrial  development  of  our 
country  from  both  the  standpoint  of  capital  and  labor  but  with  the 
necessary  governmental  supervision  over  the  human  relationship 
between  each  that  would  forever  eradicate  the  wasteful  warfare  which 
has  been  waged  between  them  in  the  past. 

Second,  establishing  at  once  a  nation-wide  program  for  the  preven- 
tion of  disease  and  accidents,  not  only  in  industry  but  in  every  walk 
of  life. 

Third,  the  immediate  federalization  of  the  health  agencies  of  the 
country  with  the  necessary  adjuncts  to  carry  out  such  a  program.  If 
the  present  great  medical  machine  which  has  been  built  up  for  miHtary 
purposes  is  allowed  to  disband  the  greatest  opportunity  for  a  system 
of  socialized  medicine  will  have  been  lost.  The  great  machine  for 
food  conservation  which  has  been  formed  is  one  of  the  well-organized 
adjuncts  necessary  for  the  above  program.  Safety  and  sanitary 
engineering  have   entered  into  the   activities  of  the  government  as 


758  INDUSTRIAL   MEDICINE    AND    SURGERY 

never  before  during  this  present  emergency;  these  also  are  essential 

auxiliaries  in  a  comprehensive  health  plan. 
Fourth,  a  scheme  which  would  provide  for: 

(a)  The  necessary  financial  relief  or  compensation  in  case  of 
disability  for  every  essential  producing  person  in  the  country. 
(6)  The  necessary  funds  to  be  raised  by  compulsory  contribution 
prorated  between  the  employer,  employee,  the  individual 
and  the  state;  the  premium  rate  to  be  arranged  on  a  sHding 
scale,  assessed  annually,  and  based  upon  the  amount  of 
sickness  or  the  accident  rate  occurring  among  each  group 
during  the  preceding  year.  Thus  the  contribution  from 
the  employer  would  depend  upon  the  size  of  his  working 
force,  plus  the  sickness  and  accident  rate  among  them.  The 
contribution  from  the  employee  would  depend  upon  his  wages, 
plus  the  sickness  and  accident  rate  among  the  employees 
in  that  particular  industry.  The  contribution  from  the 
individual  would  depend  upbn  his  individual  income  plus 
his  personal  sickness  and  accident  rate.  The  contribution 
from  the  state  would  depend  upon  the  insured  population 
plus  the  reduction  or  increase  in  the  sickness  and  accident 
rate.  Such  a  plan,  affecting  as  it  does,  the  pocket-book 
of  every  individual  would  be  the  greatest  incentive  for 
prevention  that  could  be  conceived. 

(c)  A  cumulative  fund  raised  from  a  premium  rate,  sUghtly  in 
excess  of  that  needed  for  health  insurance  and  to  be  used  as 
insurance  against  old  age,  non-employment  and  death. 

(d)  The  necessary  medical  and  surgical  relief  to  be  given  by  that 
branch  of  the  medical  profession  assigned  to  treatment. 

Fifth,  the  medical  forces  of  the  country  would  be  divided  into 
teaching  groups,  prevention  groups,  and  treatment  groups.  Subdi- 
visions of  these  divisions  would  include  executives,  consultants  and 
field  workers.  Compensation  would  be  paid  from  the  fund  raised  for 
insurance  and  would  be  commensurate  to  the  average  fees  received 
by  physicians  under  the  old  plan  of  individual  practice.  Great 
fortunes  would  no  longer  be  made  in  the  practice  of  medicine;  neither 
would  our  great  scientists,  devoting  their  time  to  research  work, 
go  underpaid  as  in  the  past.  Incompetents  in  the  profession  who 
have  gained  wealth  by  quackery  methods  or  who  have  remained  poor 
because  of  their  incompetency  would  be  eliminated.  Medical  science 
would  become  standardized  and  a  better  system  of  medicine  would  be 
universally  practiced.  Every  section  of  the  country,  and  every  district 
in  that  section,  would  have  its  qualified  medical  forces.  Wastage, 
as  at  present,  from  duplication  of  effort  would  cease. 

Such  a  comprehensive  plan  as  the  above  would  have  been  con- 


HEALTH    INSURANCE  759 

sidered  the  dreams  of  an  idealist  before  this  war,  and  by  many  may 
still  be  so  considered,  but  the  war  has  advanced  every  social  reform 
a  hundred  years.  To-day  it  behooves  the  thoughtful  man,  both  in 
and  out  of  our  profession,  to  take  for  a  standard  the  most  ideal  plan 
that  can  be  conceived  and  from  it  to  work  out  a  practical  solution  of 
these  problems.  These  are  the  by-products  of  the  war  which  will 
make  worth  while  the  great  sacrifices  which  are  being  made  by  our  men 
to-day  on  Flanders  Fields. 


CHAPTER  XL VI 
EMPLOYEES'  MUTUAL  BENEFIT  ASSOCIATIONS 

Employees'  Benefit  Associations  represent  a  form  of  industrial  in- 
surance long  in  existence  in  this  country.  This  form  of  protection  was 
sought  for  and  organized  by  the  workmen  themselves.  As  these  asso- 
ciations grew  in  favor  and  demonstrated  a  real  economic  function, 
employers  began  to  encourage  them  by  contributing  to  their  funds  or 
by  co-operating  in  their  management. 

To-day  over  500  Mutual  Benefit  Associations,  scattered  through  an 
equal  number  of  industries  the  managements  of  which  strongly  sup- 
port them,  testify  to  the  value  of  sick  benefits  for  disabled  employees. 
Their  greatest  economic  value,  however,  has  been  to  focus  the  attention 
of  the  country  upon  the  need  of  a  state-controlled  system  of  health 
insurance. 

The  development  of  employees'  benefit  associations  in  this  country 
has  had  a  very  close  relationship  to  the  development  of  industrial 
medicine.  It  is  desirable,  therefore,  that  the  physician  in  industry 
should  become  familiar  with  these  organizations  and  whenever  possible 
stimulate  their  growth. 

The  author  is  greatly  indebted  to  Mr.  W.  L.  Chandler,  one  of  the 
greatest  authorities  in  this  country  on  this  subject,  for  the  following 
article  on  Employees'  Benefit  Associations: 

"  The  form  of  Mutual  Benefit  Associations  which  has  developed 
during  years  past  is  known  to  employers  in  a  general  way.  In  the  past 
each  group  of  employees  has  been  working  out  its  own  salvation,  deter- 
mining upon  amounts  of  benefits  and  dues  in  keeping  with  their 
particular  requirements.  Originally  these  were  organized  by  the  em- 
ployees. Of  recent  years  the  employers  have  come  to  recognize  their 
value  not  only  to  the  wage-earners  but  to  the  corporation,  and  as  a 
result  of  that  feeling  together  with  the  growing  tendency  of  employers 
to  take  more  interest  in  the  welfare  of  their  men,  there  has  come  to 
be  a  co-operative  spirit  in  the  management  of  these  associations,  which 
pay  daily  benefits  in  case  of  disability  from  either  sickness  or  accident 
and  final  benefits  in  case  of  death. 

"  Three  Different  Forms  of  Organization. — The  relative  values  of 
the  three  forms  of  organizations  are  best  reflected  in  the  following 
figures,  taken  from  a  report  of  the  Commissioner  of  Labor: 

"  Of  more  than  400  organizations  in  the  United  States  those  operated 

760 


employees'  mutual  benefit  associations  761 

solely  by  employees  enjoyed  an  average  membership  of  30  per  cent, 
of  the  employees  eligible  for  membership.  In  organizations  where 
employer  and  employee  co-operated  in  the  management  the  member- 
ship averaged  66  per  cent.,  while  in  those  associations  managed  entirely 
by  employers  the  membership  averaged  75  per  cent. 

"  In  spite  of  these  figures,  75  per  cent,  of  the  Associations,  according 
to  the  Government,  were  managed  by  employees  alone,  18  per  cent, 
were  managed  jointly  by  employer  and  employee,  and  7  per  cent,  by 
the  employer  alone. 

"  The  present  tendency  is  toward  co-operation  on  the  part  of  the 
employer.  Associations  which  have  been  organized  in  recent  years 
are  nearly  all  co-operative.  By  failing  to  co-operate  with  an  effort 
of  this  kind  among  his  employees  an  employer  is  in  reality  withholding 
from  them  the  benefits  which  they  might  obtain  through  his  advice 
and  counsel.  It  is  assumed  that  the  employer  by  virtue  of  his  broader 
business  experience  is  able  to  offer  advice  of  great  value  to  the  men. 

"  How  Should  Membership  be  Obtained — Compulsory  or  Other- 
wise?— The  compulsory  form  of  membership  unquestionably  pro- 
duces the  highest  percentage  of  members.  Observation  of  a  number 
of  Associations  operating  on  that  plan  has  shown  several  serious  weak- 
nesses in  the  plan.  Every  item  of  a  compulsory  nature  which  is 
injected  into  an  establishment  has  the  effect  of  increasing  friction 
between  the  employer  and  employed. 

"  Some  employees  have  outside  insurance.  Others  have  reasons  for 
not  wanting  to  join  such  an  organization.  These  naturally  resent  com- 
pulsory membership.  There  is  another  type  of  man  who  needs  the 
protection  and  could  be  led  to  join  the  organization,  but  the  moment 
he  is  coerced  he  is  immediately  antagonized,  feeling  resentful  toward 
the  association  and  the  employer. 

"  Still  greater  evil  in  the  compulsory  membership  plan  comes 
from  the  fact  that  the  time  keepers  or  other  clerks  who  administer  the 
benefits  or  collect  the  dues  unconsciously  develop  habits  of  autocracy, 
which  inevitably  manifest  themselves  in  their  remarks  and  actions. 
These  things  very  quickly  increase  any  tendency  to  friction  between 
the  employer  and  the  working  force. 

"  Voluntary  Membership  Should  be  Followed. — The  next  thing  is 
to  develop  selling  plans  which  will  lead  to  80  or  90  per  cent,  of  the 
employees  becoming  members.  This  can  be  and  is  being  done  in 
many  institutions.  The  one  most  effective  selling  plan  is  to  secure 
the  co-operation  of  the  employment  manager  and  foremen.  When 
a  man  comes  on  to  a  new  job  is  the  psychological  moment  to  get  his 
membership.  One  essential  in  a  case  of  this  kind  is  to  have  an  enthu- 
siastic membership,  so  that  any  inquiries  on  his  part  will  result  in 
favorable  response  from  fellow  workers.     To  secure  this  the  member- 


762  INDUSTRIAL    MEDICINE    AND    SURGERY 

ship  must  be  in  mind  also  to  keep  them  informed  of  the  favorable 
progress  being  made. 

"  Some  corporations  have  offered  bonus  plans  to  departments  secur- 
ing a  satisfactory  percentage  of  membership.  These  have  not  seemed 
to  work  out  satisfactorily  because  of  the  difficulty  of  administration. 

"Benefits  and  Average  Cost  to  Employees. — While  the  cost  is  of  the 
most  interest  to  employers  and  employees,  the  amount  of  dues  must 
necessarily  hinge  upon  the  amount  of  benefits  paid  to  members. 
Statistics  covering  about  600  organizations  show  that  one  dollar 
($1.00)  per  day  for  disability  due  to  either  sickness  or  accident, 
beginning  on  the  fourth  day  after  disability  begins  and  continuing 
for  not  to  exceed  thirteen  weeks,  is  by  far  the  most  popular  form  of 
benefit.  Under  present  wage  conditions  it  seems  inadequate.  Using 
this  benefit  as  a  basis  of  calculation,  it  develops  that  with  about  350,000 
members  the  cost  for  such  benefits  should  run  less  than  ten  cents  per 
week,  allowing  a  factor  of  safety  of  about  one-third. 

"Coupled  with  the  disability  benefits  we  almost  invariably  have 
death  benefits  of  $100.00.  Such  a  death  benefit  calls  for  weekly  dues 
of  two  and  one-half  cents  (2}-^^.).  These  two  benefits  combined 
produce  a  total  of  twelve  and  one-half  cents  (123-^^.)  per  week.  The 
amount  of  benefits  may  be  varied  greatly  to  suit  different  conditions. 
The  cost  should  be  in  proportion  provided  the  membership  is  repre- 
sentative; that  is,  that  it  embraces  at  least  70  per  cent,  of  the  number 
of  employees  and  that  there  are  in  the  association  200  or  300  members. 
The  organizations  of  500  members  are  able  to  benefit  from  the  experi- 
ence of  the  wider  average  of  members. 

"Rather  than  to  allow  the  secretary  or  other  official  of  the  association 
to  collect  dues  by  calling  on  the  members,  most  of  which  would  be  done 
on  company  time,  it  is  far  better  for  the  employer  and  immensely 
more  successful  for  the  association  to  have  the  dues  deducted  from  the 
pay,  the  member  signing  an  order  on  the  paymaster  for  that  purpose. 
This  has  been  found  to  be  practically  the  only  successful  way  of  collect- 
ing dues. 

"Employer's  Contribution. — Employees  do  not  look  for  and  it  seems 
unwise  for  an  employer  to  make  contributions  to  an  association  of 
this  kind.  Such  contributions' immediately  give  rise  to  wonderment 
as  to  the  motive  behind  them  and  frequently  result  in  unfavorable 
impressions.  Any  contributions  on  the  ^  part  of  the  employer  should 
be  made  in  the  form  of  his  co-operation  in  an  advisory  capacity  and  by 
permitting  one  or  more  employees  to  devote  such  time  as  may  be 
required  to  the  intelligent  conduct  of  the  work.  The  average  mind 
does  not  recognize  such  as  a  contribution  on  the  part  of  the  employer. 
Such  an  employee  may  be  of  inestimable  value  to  the  association  and 
accordingly  to  the  employer. 


employees'  mutual  benefit  associations  763 

"Forms  of  Benefits. — In  a  very  few  of  these  associations  it  is  cus- 
tomary to  make  the  benefits  a  given  percentage  of  the  wages.  That 
plan  offers  some  advantages,  but  on  the  other  hand  there  are 
many  disadvantages  due  to  obstacles  encountered  in  administration. 
The  calculation  and  deduction  of  dues  each  week  or  pay  day  in- 
volves a  good  deal  of  clerical  work  and  chance  for  error,  and  it  is 
generally  considered  that  the  fixed  amount  of  benefits  and  dues  are 
preferable. 

"Some  organizations  provide  for  different  amounts  of  benefits  and 
corresponding  dues  to  take  care  of  those  members  who  realize  the  value 
of  the  protection.  Sociologists  and  others  who  have  carefully  analyzed 
the  situation  have  reached  the  conclusion  that  benefits  should  begin 
on  the  fourth  day  following  the  beginning  of  disability.  This  elimi- 
nates that  large  number  of  cases  of  one,  two  and  three  days  duration. 
Cases  of  three  days  do  not  involve  a  member  in  any  financial  em- 
barrassment but  what  he  can  overcome.  If  benefits  were  made  to 
include  these  three  days  of  disability  the  large  number  of  short  time 
cases  would  prove  a  very  heavy  drain  on  the  treasury  and  result  in 
much  higher  dues  being  necessary  to  carry  the  insurance.  After  all, 
the  benefits  are  purely  a  matter  of  what  the  men  are  willing  to  pay  for. 
It  is  unwise  though  to  select  benefits  which  call  for  dues  so  high  as  to 
prove  unattractive. 

"Some  associations  have  a  plan  in  force  whereby  members  disabled 
for  more  than  two  weeks  receive  benefits  for  the  first  three  days  as  well. 
This  is  a  bad  practice,  because  it  is  equivalent  to  offering  a  bonus  for 
prolonged  sickness.  For  example,  if  a  member  is  sick  a  little  less  than 
two  weeks  he  will  be  very  quick  to  realize  that  if  he  will  only  pretend 
sickness  for  the  balance  of  the  two  weeks  the  association  will  not  only 
pay  him  the  benefits  for  those  few  days  but  in  addition  will  hand  him  a 
bonus  of  benefits  covering  the  first  three  days  of  disability. 

"Benefits  are  regularly  paid  for  thirteen  weeks  covering  either 
sickness  or  accident.  Work  accidents  as  well  as  those  occurring 
outside  of  the  plant  are  almost  invariably  included.  In  the  cases  of 
men  drawing  compensation  it  sometimes  happens  that  members  are 
receiving  benefits  in  excess  of  wages.  This  will  result  in  malingering 
unless  something  is  done  to  counteract  the  influence.  A  provision  in 
the  By-laws  where  benefits  from  all  sources  shall  not  exceed  90  per  cent, 
of  wages  has  been  successfully  used  in  the  association  among  employees 
of  the  Dodge  Manufacturing  Company. 

"In  the  case  of  salaried  people  benefits  under  this  plan  cannot 
begin  until  salary  ceases.  In  cases  of  compensation  for  injurj^  the 
Indiana  law  provides  for  55  per  cent,  of  wages  after  the  first  week. 
The  association  pays  full  benefits  for  the  last  four  days  of  the  first  week 
and  the  difference  between  55  per  cent,  and  90  per  cent,  thereafter, 


764  INDUSTRIAL    MEDICINE    AND    SURGERY 

provided  it  does  not  exceed  the  amount  of  insurance  carried  by  the 
member. 

"Free  Medical  Care. — One  very  Hve  topic  among  organizations  at 
this  time  is  that  of  free  medical  care.  There  seems  to  be  very  Httle 
in  the  way  of  crystaUized  opinion  on  that  subject,  although  some- 
thing definite  should  result  from  so  much  thought  being  applied  to 
the  subject. 

"In  cases  where  employers  have  industrial  physicians  attached 
to  the  plants  certain  medical  care  has  been  given,  but  in  all  of  these 
cases  the  disposition  seems  to  be  to  make  this  a  contribution  of  the 
employer  rather  than  of  the  association.  It  remains  for  some  in- 
dustrial physician  to  evolve  a  plan  whereby  such  associations  may 
render  medical  assistance  to  members  without  encountering  the  dis- 
advantages which  have  so  far  led  to  failure  wherever  attempts  have 
been  made. 

"The  Human  Side  of  Employees  Benefit  Associations. — A  well 
handled  organization  may  be  made  the  means  of  many  other  self 
helps  for  employees.  Going  back  to  the  case  of  loss  in  production  due 
to  worry  of  the  workers.  We  may  consider  the  cases  of  men  worried 
over  their  debts  as  well  as  over  sickness.  The  more  these  men  are 
worried  the  less  '  pep '  they  have  and  the  lower  production  drops. 

"I  recall  one  case  of  a  man  who  borrowed  $80.00  of  a  loan  shark, 
and  after  paying  $1.00  per  week  for  eight  years  he  still  owed  $47.00  of 
the  loan.  This  matter  was  brought  to  the  attention  of  the  officers  of 
the  E.  B.  A.  Investigation  showed  that  these  loans  had  been  made 
each  month  for  thirty  days  and  that  interest  and  renewal  charges  had 
almost  eaten  up  all  that  he  paid  in,  which  accounted  for  the  condition 
of  the  account. 

"Another  man  received  $55.00  from  a  loan  shark  and  gave  his 
thirty  day  note  for  $60.00.  At  the  end  of  the  month  he  attempted  to 
pay  $5.00  on  the  principal.  He  discovered,  however,  that  it  would 
cost  him  $3.00  to  renew  the  remaining  $55.00  and  that  the  interest  for 
the  thirty  days  amounted  to  $2.00,  so  that  it  took  all  of  his  $5.00  pay- 
ment to  make  up  the  interest  and  the  renewal  charge;  consequently, 
he  still  owed  $60.00  after  paying  $5.00.  This  had  continued  for  twelve 
months.  Each  month  he  had  paid  $5.00  without  making  any  im- 
pression upon  the  note.  This  was  also  brought  before  the  officers 
of  the  same  organization.  In  the  first  case  the  matter  was  placed 
forcibly  before  the  shark  and  the  man  was  told  to  refuse  further  pay- 
ment and  that  the  E.  B.  A.  would  see  him  through  in  case  of  trouble. 
In  the  second  case,  arrangements  were  made  to  take  up  the  loan  and 
handle  it  upon  a  more  just  basis  through  another  medium. 

"  Unfortunately  the  human  being  is  not  normally  gifted  with  the 
ability  to  accumulate  money.     The  thrift  habit  seems  to  be  absolutely 


employees'  mutual  benefit  associations  765 

an  acquired  taste,  requiring  pretty  strong  incentives  to  develop  it. 
Every  person  has  occasional  need  for  cash  in  excess  of  that  on  hand. 
These  cases  may  be  at  the  time  of  moving,  buying  furniture,  putting 
in  the  winter's  coal  or  potatoes,  in  case  of  sickness,  childbirth,  death, 
etc.  Regardless  of  the  cause,  some  proper  method  of  satisfying  the 
need  must  be  created  if  an  employer  is  going  to  prevent  the  disastrous 
results  among  his  workers  which  will  surely  follow  if  they  get  into  the 
hands  of  loan  sharks. 

"  Experience  shows  that  these  money  lenders  are  often  found  right 
in  the  plant.  Some  foremen  have  been  found  to  conduct  loaning 
schemes  with  very  injurious  results,  so  that  they  often  exist  where  we 
least  suspect  them. 

"  An  employee  who  finds  it  necessary  to  frequently  borrow  money 
somewhere  back  in  the  rear  of  his  head  has  a  notion  that  he  is  not  paid 
sufficiently  to  permit  a  proper  living.  It  is  among  such  men  that  labor 
agitators  find  a  very  fertile"  field.  A  man  who  has  not  developed  the 
thrift  habit  will  never  be  out  of  debt,  no  matter  how  much  his  wages 
amount  to. 

"  We  are  now  up  to  the  point  of  developing  a  vision  for  the  man. 
We  must  bring  him  to  a  point  where  he  wants  something  and  wants  it 
very  much  and  where  he  can  see  that  by  systematic  saving  he  may 
be  able  to  secure  the  thing  he  thus  desires.  If  we  can  bring  him  to 
see  the  value  to  himself  of  a  bank  account  he  will  do  the  rest.  He 
must  have  more  than  a  hazy  glimpse  of  money  in  the  bank.  He 
needs  a  firmly  implanted  vision  of  the  nearness  of  the  things  he  wants 
so  that  he  will  not  look  upon  the  task  as  a  hopeless  one.  If  he  ever 
gets  such  a  vision  you  cannot  stop  him. 

''  To  bring  this  situation  about  the  E.  B.  A.  should  be  induced  to 
add  to  its  activities  the  function  of  a  Thrift  Club.  On  account  of  legal 
technicalities  it  may  seem  desirable  to  go  through  the  formalities  of  a 
separate  Club,  electing  the  same  officers  as  those  for  the  E.  B.  A.,  so 
that  the  work  of  the  two  may  be  handled  without  the  need  for  separate 
meetings. 

"  These  Thrift  Clubs  are  doing  wonderful  work  in  teaching  men 
to  make  ends  meet,  instilling  the  principle  of  Thrift  into  the  remotest 
corners  of  the  plant.  One  man  who  had  been  in  debt  for  fifteen  years 
and  honestly  believed  that  he  did  not  receive  enough  to  permit  him  to 
live  decently  has  demonstrated  not  to  others  but  to  himself  that  he  is 
able  to  get  out  of  debt  and  in  time  to  pay  for  his  home.  Many  of  these 
cases  are  very  touching  and  provide  the  greatest  amount  of  encourage- 
ment to  those  who  are  instrumental  in  promoting  such  Thrift 
Clubs. 

"The  Employees'  Benefit  Association  in  Preventive  Work. — In 
endeavoring  to  reach  employees  with  any  new  line  of  thought  it  is 


766  INDUSTRIAL   MEDICINE    AND    SURGERY 

necessary  to  begin  on  the  plane  in  which  they  are  in  the  habit  of  think- 
ing. For  example,  imagine  a  manufacturing  plant  where  the  toilet 
facilities  have  been  left  pretty  largely  to  each  department  to  look 
after  and  nothing  out  of  the  ordinary  provided  in  the  way  of  toilet 
rooms — no  tile  floors  or  walls,  merely  ordinary  kind  of  janitor  service, 
etc.  In  a  great  many  cases  it  has  been  shown  clearly  that  under 
such  circumstances  these  toilets  will  be  quite  unsanitary;  in  fact,  to 
one  who  has  been  accustomed  to  properly  maintained  toilet  facilities 
they  are  especially  offensive. 

"A  physician  entering  such  a  plant  would  naturally  be  very  un- 
favorably impressed  with  the  toilets,  and  his  first  desire  would  be  to 
clean  them  up,  buy  new  and  modern  equipment  and  to  insist  that 
they  be  kept  in  a  highly  sanitary  condition.  Such  toilets  would  fail 
absolutely  because  the  employees  have  grown  accustomed  to  the  kind 
they  are  using  and,  in  fact,  such  toilets  really  reflect  the  minds  of  the 
majority  of  the  men  who  use  them;  otherwise,  they  would  be  more 
sanitary.  Before  those  toilets  can  ever  be  fully  sanitary  and  main- 
tained in  that  condition  the  material  make-up  of  the  men  must  be 
changed. 

"  This  illustration  I  am  applying  to  toilet  facilities  has  a  similar 
bearing  upon  any  phase  of  health  movements.  A  physician  desiring 
to  improve  the  condition  of  men  in  a  plant  will  then  find  the  most  valu- 
able assistance  in  the  Employees'  Benefit  Association.  This  organi- 
zation is  of,  by  and  for  the  employees.  They  have  certain  needs  and 
have  learned  to  recognize  their  problems.  A  physician  by  beginning 
with  their  viewpoint  will  find  that  they  are  much  more  ready  to  follow 
his  teachings  than  if  he  starts  with  any  other  point  of  view. 

"As  a  side  light  on  the  value  of  preventive  medicine  to  the  em- 
ployer, there  is  in  mind  an  instance  in  a  large  plant  during  the  Influenza 
Epidemic  of  1918.  This  employer  called  together  all  the  departmental 
foremen  to  listen  to  a  talk  by  the  physician.  In  this  talk  they  were 
informed  of  the  various  symptoms  by  which  they  might  recognize 
certain  possible  victims  of  the  epidemic.  After  the  physician  had 
finished  the  foremen  were  instructed  to  keep  their  eyes  open  for  workers 
who  showed  any  of  these  symptoms  and  that  such  be  immediately 
referred  to  the  medical  department.  As  a  matter  of  fact,  only  about 
one-third  of  those  referred  for  examination  proved  to  have  influenza 
or  anything  which  might  lead  to  it,  so  that  only  one-third  were  sent 
home  and  given  medical  treatment. 

"The  illuminating  part  of  this  instance  develops  through  one 
foreman  who  did  not  co-operate.  A  week  or  two  after  this  particular 
foremen's  meeting  it  developed  that  the  plant  was  in  rather  favorable 
condition  except  one  department  and  that  was  nearly  shut  down  be- 
cause so  many  of  the  employees  were  sick  with  influenza.     Investiga- 


employees'  mutual  benefit  associations  767 

tion  disclosed  the  fact  that  this  foreman  thought  that  precautions  of 
this  kind  were  unnecessary,  so  he  paid  no  attention  to  the  instructions, 
preferring  to  keep  a  man  on  the  job  as  long  as  he  could  stick.  He  had 
made  no  effort  to  watch  his  men,  allowing  them  to  do  as  they  pleased 
about  coming  to  work.  When  the  management  discovered  the  real 
situation  it  became  necessary  to  thoroughly,  fumigate  the  whole 
department  and  to  make  physical  examinations  of  everyone  in  it 
who  was  not  yet  sick,  sending  home  those  who  showed  symptoms. 
The  loss  in  production  in  that  department  was  exceedingly  great  for 
the  following  two  weeks.  The  contrast  between  this  department  and 
the  others  was  very  conclusive  evidence  of  the  value  of  this  preventive 
medicine. 

"  On  the  whole,  the  interest  in  Employees'  Benefit  Associations  is 
growing  constantly.  Corporations  throughout  the  country  are  en- 
couraging employees  to  form  organizations  of  this  kind  and  are  co- 
operating with  them  to  increase  the  membership.  '  Evidence  is 
conclusive  that  they  have  proven  a  real  asset  to  the  employer  wherever 
installed." 


Part  VI 
RECONSTRUCTION 


CHAPTER  XLVII 
AMERICANIZATION  OF  THE  FOREIGN  EMPLOYEE 

THE  INDUSTRIAL  SURGEON'S  PLACE  IN  THIS  PROGRAM 

Another  great  benefit  of  the  present  war  has  been  the  awakening 
of  our  nation  to  the  fact  that  a  large  proportion  of  its  citizenry  is 
composed  of  foreigners  who  have  never  become  americanized.  We 
have  welcomed  these  immigrants  to  our  shores  but  have  made  no  con- 
certed, national  effort  to  assimilate  them.  Content  with  the  knowledge 
that  in  one  or  two  generations  they  would  become  good  Americans, 
we  have  allowed  the  recent  arrivals  to  live,  think,  eat,  drink  and  act 
as  foreigners. 

The  great  number  of  naturalized  foreigners  who  still  gave  their 
full  allegiance  to  the  home  country  has  awakened  us  to  our  shortsight- 
edness in  this  connection.  The  Bolsheviki  movement  in  Russia  was 
augmented,  more  than  is  generally  known,  by  the  peoples  from  that 
country  who  lived  in  our  midst  for  years  as  radicals  and  anarchists 
and  then  were  allowed  to  return  to  Russia  to  spread  the  seeds  of 
discontent  and  even  of  hatred  of  the  United  States  throughout  the 
ignorant,  dissatisfied  radical  element  of  Russia.  Our  failure  to  ameri- 
canize  these  peoples  places  a  part  of  the  responsibility  for  Russia's 
downfall  upon  our  shoulders. 

These  facts  are  awakening  the  nation  to  its  duty  toward  the  large 
foreign  population  which  dwells  in  the  land.  Whether  we  have  suffi- 
ciently learned  our  lesson  to  profit  by  it  remains  to  be  seen. 

Already  the  army  has  done  excellent  work  in  making  real  citizens 
out  of  the  foreign  draftees.  Such  men  as  Taft  and  Roosevelt  have 
stirred  the  country  by  their  pleas  for  a  united  American  citizenry  in 
the  future.  The  Carnegie  Foundation  has  recently  given  a  large  sum 
of  money  for  the  creation  of  a  permanent  organization  whose  functions 
are  best  described  by  its  name — "Study  of  Methods  of  Americaniza- 
tion." These  efforts  are  prophetic  of  the  changed  attitude  of  the 
country. 

The  medical  profession,  and  especially  those  physicians  who  are 
49  769 


770  INDUSTRIAL   MEDICINE    AND    SURGERY 

connected  with  large  industries,  come  in  very  close  contact  with  this 
foreign  element;  see  them  at  their  work  and  at  home;  and  realize  more 
than  most  people  the  needed  reforms  in  order  to  make  the  immigrant 
more  nearly  like  the  remainder  of  the  population.  It  is  imperative, 
therefore,  for  the  physician  to  take  a  prominent  part  in  this  american- 
ization  program  and  to  point  out  to  industry,  the  community  and  the 
state  their  responsibilities  and  the  corrective  measures  needed. 

How  many  times  has  the  physician  in  industry  been  confronted 
with  cases  similar  to  the  following : 

John  Zurowsky  had  worked  for  his  concern  four  years.  He  was 
a  good,  faithful  employee,  but  had  not  advanced  because  he  could 
neither  read  nor  write  English  and  spoke  it  very  poorly.  His  foreman 
noticed  that  John  was  looking  badly  and  had  lately  fallen  behind  in 
his  work.     He  was,  therefore,  sent  to  the  doctor's  office. 

A  nurse  who  talked  John's  language  learned  that  his  wife  and  one 
of  his  children  were  very  sick  and  John  had  been  up  nursing  them  at 
night  for  several  weeks.  They  had  been  treated  by  four  different 
doctors  until  all  of  his  savings  were  spent.  Then  he  had  taken  his 
child  to  the  free  dispensary  and  sent  his  wife  to  the  County  Hospital. 
The  doctors  at  the  hospital  had  advised  an  operation,  but  as  no  one 
there  could  talk  to  her  she  insisted  on  coming  home.  The  child  might 
have  been  helped  at  the  free  dispensary  but  the  mother  was  not  able 
to  take  her  there  and  the  father  had  to  work  in  the  daytime.  For 
the  last  month  he  had  been  giving  them  "Easymon"  which  a  neigh- 
bor said  was  a  sure  cure,  and  showed  him  a  Polish  paper  which  also 
extolled  the  medicine.  In  spite  of  all  this  his  wife  and  child  were 
growing  worse. 

The  plant  physician  and  the  nurse  visited  John's  home  at  once. 
He  lived  in  a  squalid,  foreign  neighborhood,  in  a  flat — third  floor,  rear. 

There  were  five  children,  the  oldest  aged  ten,  and  John  and  his 
wife  living  here  in  four  rooms.  The  rooms  were  filthy  because,  as 
John  explained,  the  children  mussed  them  up  during  the  day  even 
though  he  cleaned  up  good  at  night.  The  windows  were  tightly  closed 
and  sanitary  conditions  were  of  the  worst. 

The  wife  was  examined  and  found  to  have  an  inoperable  cancer  of 
the  uterus.  This  was  undoubtedly  found  at  the  hospital  but  when  she 
left  no  agency  of  the  county  saw  fit  to  follow  up  the  case.  The  cancer 
could  not  have  been  diagnosed  by  any  one  of  the  four  doctors  who  had 
treated  her,  as  none  of  them  had  made  an  examination. 

The  child  was  found  to  have  a  pulmonary  tuberculosis  which  had 
evidently  not  been  diagnosed  on  the  one  visit  to  the  free  dispensary. 

The  conditions  in  this  home  were  explained  to  the  management  and 
the  doctor  was  told  to  spare  no  expense  in  helping  them  as  far  as  possi- 
ble at  this  late  stage. 


AMERICANIZATION    OF    THE    FOREIGN    EMPLOYEE  771 

John's  wife  was  sent  to  a  hospital  where  she  occupied  a  bed  in  a 
two-bed  ward.  The  entire  history  of  the  case  was  told  to  the  nurses 
and  they  were  stimulated  to  exert  themselves  to  the  utmost  to  make 
amends  for  the  poor  woman's  past  sufferings.  She  was  kept  here 
until  her  death  six  weeks  later. 

The  child  was  sent  to  a  tuberculosis  sanatorium,  the  expenses  being 
paid  by  the  management,  and,  after  a  year,  recovered. 

A  small  house  in  the  suburbs,  which  rented  for  exactly  the  same 
sum  that  John  had  been  paying,  was  found  for  the  rest  of  the  family. 
His  wages  were  increased  so  he  could  afford  to  employ  a  housekeeper. 
An  American  woman  was  found  for  this  position  and  she  was  a  marvel 
in  americanizing  John  and  his  children. 

The  lessons  which  this  foreigner's  case  point  out  are  characteristic 
of  hundreds  of  thousands  of  other  immigrant  employees  in  the  various 
industries  of  the  country  to-day.     These  can  be  summarized  as  follows  : 

1.  Different  standards  of  living  in  his  foreign  home. 

2.  Crowding  into  a  tenement  in  that  portion  of  the  city  where 
those  of  his  own  nationality  had  congregated. 

3.  No  incentive  to  learn  our  language  or  our  standards  of  living. 

4.  Inadequate  wages  to  provide  proper  food  and  proper  living 
conditions  for  his  family. 

5.  Ignorance  of  our  language  and  our  customs  prevented  proper 
treatment  of  his  wife's  condition.  (The  four  doctors'  failure  to  examine 
her  prevented  an  early  diagnosis  of  the  case.) 

6.  Insanitary  surroundings  caused  his  child's  tuberculosis. 

7.  Finally,  interest  on  the  part  of  his  employer  enabled  the  correc- 
tion of  all  these  conditions — except  that  this  interest  came  too  late  to 
save  his  wife. 

The  problem  of  the  immigrant  employee  is  the  problem  of  industry 
and  of  the  community.  The  medical  staffs  in  industry  and  the 
municipal  public  health  services  can  render  the  greatest  assistance 
in  solving  this  problem. 

The  existing  national  emergency  has  demonstrated,  however,  that 
this  is  a  national  problem  and  one  which  the  Federal  government 
must  tackle.  National  health  and  educational  commissions  are  neces- 
sary to  properly  cope  with  the  situation,  not  only  for  the  foreign-born 
citizens  but  for  the  native  American;  the  war  has  demonstrated  the 
extent  of  ilhteracy  among  our  people. 

Miss  Ifinda  James  of  the  executive  staff  of  the  society  for  the 
"Study  of  Methods  of  Americanization"  has  made  the  following 
contribution  to  this  book  in  which  she  most  forcibly  expresses  the 
part  which  industrial  medicine  can  play  in  these  problems  of  the  im- 
migrant employee. 

"The  immigrant  has  come  to  play  such  an  important  part  in  the 


772  INDUSTRIAL   MEDICINE    AND    SURGERY 

life  of  our  nation  to-day  that  it  has  become  necessary  to  give  special 
attention  to  the  problems  which  he  has  brought  with  him.  Among 
these  is  that  of  his  relation  to  the  industrial  world.  "While  probably 
all  manufacturers  are  conscious  that  they  employ  numbers  of  foreign- 
ers, a  few  figures  may  make  more  evident  the  importance  of  giving 
•special  consideration  to  this  group  in  industry  to-day. 

"In  1908-1909  the  United  States  Immigration  Commission  made 
an  investigation  of  'Immigrants  in  Industries'  which  contains  much 
valuable  material  for  the  industrial  physician.  It  has  been  condensed 
by  Jenks  and  Lauck  in  their  book^  from  which  the  following  quotations 
were  taken: 

"  'It  was  found  that  only  one-fifth  of  the  total  number  of  wage- 
earners  in  twenty-one  of  the  principal  branches  of  industry  were  native 
white  Americans,  while  almost  three-fifths  were  of  foreign  birth;  17 
per  cent,  were  industrial  workers  of  the  second  generation,  or  of  native 
birth  but  of  foreign  father,  and  5  per  cent,  were  native  negroes.  About 
30  per  cent,  of  all  the  females,  as  contrasted  with  only  14  per  cent,  of 
the  men,  are  native  born  of  foreign  father. 

"  'Altogether,  fifty-six  distinct  races  appeared  in  the  working  forces 
of  the  mines  and  manufacturing  establishments  included  in  the  recent 
comprehensive  inquiry  of  the  Immigration  Commission.  Thirty- 
seven  of  these  races  were  of  the  south  and  east  of  Europe  or  of  the 
Orient.  Almost  one-half  of  all  the  wage-earners  were  from  southern 
and  eastern  European  countries. 

"  'The  proportion  of  foreign  born  among  the  operative  forces  of  the 
principal  branches  of  manufacturing  and  mining  were  as  follows : 

"  'More  than  one-half  of  the  iron  and  steel  workers,  employees  of 
oil  refineries,  slaughtering  and  meat-packing  establishments,  furniture 
factories,  leather  tanneries  and  finishing  establishments,  woolen  and 
worsted  goods,  and  cotton-mill  operatives;  about  two-fifths  of  the 
glass  workers;  one-third  of  the  silk-mill  operatives,  glove  factory 
employees,  and  cigar  and  tobacco  makers;  seven-tenths  of  men  and 
women  garment  makers;  more  than  one-fourth  of  the  boot  and  shoe 
factory  operatives;  four-fifths  of  the  wage-earners  in  sugar  refineries.' 

"According  to  the  United  States  Census  of  1910,  59.9  per  cent,  of 
the  foreign  born  in  this  country  were  between  the  ages  of  15  and  45 
years.  ^  This  means  that  a  large  part  of  the  immigrants  spend  at 
least  one-third  of  their  lives  in  the  industrial  world ;  consequently  the 
problem  of  assimilation  is  an  industrial  as  well  as  a  commt5nity  one. 

"Ignorance  and  lack  of  understanding  of  English  are  important 
factors  to    be  considered  in  discussing    the    relation    between    the 

1  "The  Immigration  Problem,"  Jenks  and  Lauck,  1917  edition,  pages  148-9. 
are  made: 

2  13th  Census  of  the  United  States,  1910,  "Population,"  Vol.  1,  page  307. 


AMERICANIZATION    OF    THE    FOREIGN    EMPLOYEE  773 

immigrant  employee  and  industrial  medicine.  That  many  accidents 
are  due  to  these  causes  is  an  accepted  fact.  Testimony  in  this  regard 
is  especially  plentiful  from  the  mining  fields.  ^  Their  relation  to 
industrial  disease  is  not  so  well  established.  It  is  entirely  reasonable 
to  suppose,  however,  that  certain  poisons,  like  lead  for  instance, 
would  be  a  more  serious  menace  to  a  foreigner  who  could  not  under- 
stand its  dangers  than  to  a  native  American  who  can  comprehend 
cautions  and  directions.  As  an  industrial  health  inspector  I  have 
run  across  numerous  instances  of  this  kind.  Of  the  246,673  foreign- 
born  employees  included  in  the  Federal  investigation  only  53.2  per 
cent,  spoke  English;  38.6  per  cent,  of  the  34,957  women  and  55.6  per 
cent,  of  the  211,716  men.  Of  the  incoming  immigrants  for  the  five- 
year  period  preceding  the  study  28.6  per  cent,  were  English  speaking. ^ 
An  industry  that  hopes  to  lower  its  accident  and  industrial  disease 
rates  must  then  give  consideration  to  the  question  of  illiteracy  among 
its  foreign  employees. 

"In  addition  to  the  illiteracy  of  the  more  recent  immigrants  from 
southern  and  southeastern  Europe  has  come  the  question  of  standards 
of  sanitation  which  they  bring  with  them.  Most  of  these  people  are 
peasants  direct  from  the  farms  of  Europe  who  know  nothing  of 
urban  and  industrial  conditions  and  demands.  The  condition  of 
their  homes  and  their  manner  of  living  are  much  below  the  accepted 
American  standards.^  Consequently  the  general  sanitation  of  any 
plant  is  lowered  by  their  presence  unless  measures  are  taken  to  teach 
them  our  standards. 

"The  housing  of  the  foreign  employees  outside  the  plant  is  another 
factor  to  be  considered.  When  those  who  are  used  to  farm  life  and  who 
have  low  standards  of  sanitation  are  herded  together  in  tenements, 
or  in  old  houses  formerly  occupied  by  single  families,  unhealthful 
results  can  be  expected.  In  the  more  recent  immigration  it  is  the 
young  unmarried  men  who  come  alone  first,  bringing  over  their 
families  in  the  later  years.  This  is  especially  true  among  the  Greeks 
and  certain  of  the  Slavs.  The  communal  system  of  living  developed  by 
these  single  men  leads  to  serious  overcrowding.  Thirty-four  per  cent. 
of  the  15,127  households  of  the  foreign  born  included  in  the  Federal 
study  had  seven  or  more  persons  per  household,  as  against  13.8  per 
cent,  of  the  native  born  of  native  parents;  9  per  cent,  had  ten  or  more 
per  household,  as  against   1   per  cent,   of  the  natives.     Over  three 

1  "The  Immigration  Problem,"  Jenks  and  Lauck,  1917  edition,  pages  201, 
477-9. 

2  13th  Census  of  the  U.  S.,  Vol.  I. 

^  "Our  Slavic  Fellow  Citizens,"  Balch,  Emily  G. ;  "Russian  Life  in  Town  and 
Country,"  Palmer,  F.  H.;  "The  Slav  Invasion  and  the  Mine  Workers,"  Warne^ 
F.J. 


774  INDUSTRIAL    MEDICINE    AND    SURGERY 

people  to  a  bedroom  was  a  common  finding  among  these  foreign- 
born  households.  Thirty-two  and  nine-tenths  per  cent,  of  the  15,127 
households  kept  boarders;  only  9.9  per  cent,  of  the  native  born  kept 
them.^  The  diseased  immigrant  living  under  such  conditions  is  a 
menace  to  the  community  and  to  those  living  and  laboring  with  him. 

"The  food  habits  of  the  foreigners  in  the  old  world  and  the  new  are 
also  of  interest  to  the  industrial  physician.  The  southern  Europeans 
seem  to  find  it  hardest  to  adapt  their  diet  to  the  demands  of  our 
northern  climate.  Rickets  among  the  Itahan  children — with  the 
attendent  underdevelopment  which  that  means  for  the  adult — is  a 
common  finding  by  nursing  associations  and  hospitals.  That  indus- 
trial physicians  are  thinking  about  food  in  relation  to  the  health  of 
their  immigrant  employees  is  evidenced  by  the  fact  that  out  of  70 
questionaires  recently  returned  from  them,  17  per  cent,  mentioned 
this  as  a  distinct  problem. 

"Racial  drink  idiosyncrasies  are  an  industrial  health  problem  also. 
Certain  races  (the  Italians,  Jews  and  Greeks),  though  they  drink, 
do  not  get  drunk;  while  others  (the  Irish  and  French  Canadians) 
are  noted  for  heavy  drinking.  It  is  interesting  to  note  in  this  connec- 
tion that  the  death-rate  from  tuberculosis  among  the  Irish  leads  all 
other  nationalities.  Industries  employing  chiefly  Irish  and  French 
Canadians  have  had  to  accept  the  absences  from  work  on  Mondays 
and  even  Tuesdays  because  of  the  Sunday  sprees.-  Some  plants 
have  endeavored  to  stop  drinking  of  intoxicating  liquors  during 
working  hours,  with  its  consequent  lowering  of  efficiency  and  accuracy, 
by  providing  at  cost  other  drinks  in  various  parts  of  the  building. 
Cocoa,  coffee,  milk,  soft  drinks,  etc.,  have  met  with  favor  and  with 
some  degree  of  success. 

"The  medical  care  which  is  available  to  the  immigrant  and  his 
family — with  its  effect  on  the  working  capacity  of  the  employee — is  the 
last  point  I  shall  speak  of.  One  industrial  physician  has  described  the 
present  situation  as  'highway  robbery  for  the  employee.'  And  so  it  is. 
A  first  class  doctor  cannot  be  called  in  by  the  employee  for  sickness  of 
himself  or  his  family  because  of  the  expense;  even  a  second  class  one 
charges  a  fee  out  of  keeping  with  the  income  of  the  worker.  Such  a 
thing  as  a  family  physician  is  seldom  found  among  the  foreigners. 
They  shift  from  doctor  to  doctor  on  the  advice  of  neighbors;  or  what  is 
worse  resort  to  quacks  and  patent  medicines  for  rapid  and  cheap  cures. 
A  survey  of  the  quack  medical  advertising  to  be  found  in  foreign 
language  newspapers  gives  one  an  idea  of  what  a  flourishing  business 
this  is  among  the  immigrants.     As  a  last  resort  the  employee  may  call 

1  "The  Immigration  Problem,"  Jenks  and  Lauck,  1917  edition,  pages  505 
and  507. 

2  "The  Greeks  in  America,"  Burgess,  Thomas. 


AMERICANIZATION    OF    THE    FOREIGN    EMPLOYEE  775 

on  some  charitable  organization.  This  means  that  more  days  of  work 
are  going  to  be  lost  through  illness  of  the  worker  or  his  family  than  if 
competent  and  moderate  priced  medical  care  were  within  his  reach  at 
the  beginning  of  illness.  Whether  this  is  a  problem  for  industry  to 
solve,  for  the  community,  or  for  both  to  solve  together  remains  to  be 
seen. 

*'In  conclusion  there  are  certain  important  questions  which  I  would 
Uke  to  leave  with  the  industrial  physician  for  his  further  consideration : 

"1.  How  is  industry  going  to  eliminate  industrial  accidents  and  dis- 
eases which  can  be  attributed  to  the  foreign  employee's  ignorance  and 
lack  of  knowledge  of  the  English  language? 

"2.  Is  education  advisable;  and  if  so,  should  it  be  carried  on  by  the 
industry,  by  the  public  schools,  by  private  organizations  like  the  Y.  W. 
or  Y.  M.  C.  A.,  or  by  some  other  method? 

"3.  Are  posters  and  literature  in  foreign  languages  relating  to 
accidents,  industrial  diseases,  sanitation,  and  personal  hygiene  going 
to  be  valuable  in  bettering  the  health  of  the  employee  and  his  family? 

"4:.  What  is  the  responsibility  of  industry  toward  its  immigrant 
employees  and  their  families  in  regard  to  the  following:  Medical  care 
during  illness  of  either  the  worker  or  his  family;  food,  at  home  as  well 
as  in  the  plant;  drink;  personal  hygiene;  and  housing?" 


CHAPTER  XLVIII 

HUMAN  CONSERVATION  AND  RECLAMATION  OF 
THE  DISABLED  / 

Physical  reconstruction,  rehabilitation,  functional  re-education, 
occupational  therapy,  vocational  re-education  and  similar  terms  have 
either  sprung  into  existence  or  derived  a  new  meaning  during  the 
present  world  struggle.  The  hundreds  of  thousands  of  disabled 
soldiers  returning  to  civil  life  have  made  it  necessary  for  the  nations  to 
devise  plans  for  their  reclamation.  As  a  result  a  new  viewpoint  has 
been  attained  by  the  medical  profession,  by  various  educational  agen- 
cies, by  both  industry  and  labor,  and  by  many  legislative  bodies — a 
viewpoint  which  must  be  moulded  and  adapted  to  the  reclamation  of 
the  disabled  in  civil  life. 

The  United  States,  following  the  example  of  other  warring  nations, 
has  adopted  a  plan  to  physically  reconstruct,  functionally  re-educate, 
and  completely  rehabilitate  all  of  her  disabled  soldiers.  Congress,  in 
June,  1917,  pledged  this  service  by  passing  the  War  Risk  Insurance 
Act.  The  necessity  of  conserving  our  man  power,  as  well  as  the  debt 
which  the  nation  owes  these  disabled  soldiers,  makes  such  a  program 
obligatory. 

By  physical  reconstruction  is  meant  the  continued  and  complete 
medical  and  surgical  treatment  until  the  greatest  possible  restoration 
of  the  disabled  parts  has  been  secured.  Functional  re-education  con- 
sists of  various  methods  to  restore  function  in  a  disabled  part,  or  to 
train  other  members  to  new  work,  or  to  teach  the  amputated  cases  the 
use  of  artificial  appliances.  In  other  words,  it  is  combining  with  our 
surgical  procedure,  which  aims  at  his  physical  repair,  certain  other 
therapeutic  measures  which  will  help  the  patient  to  functionally  over- 
come his  handicap.  Occupational  therapy  is  the  use  of  some  form  of 
work  which  will  bring  into  action  certain  muscles  and  members  of  the 
body  thus  assisting  in  their  functional  restoration,  or  which  will  keep 
the  mind  and  body  busy  during  the  long  period  of  convalescence  and 
thus  prevent  hospitalization  and  habits  of  idleness. 

Rehabilitation,  or  the  refitting  of  the  disabled  man  to  an  in- 
dependent economic  position  in  society,  consists  of  measures  which  are 
neither  medical  nor  surgical  but  which  can  often  begin  during  the 
course  of  his  medical  treatment.  Thus,  the  work  of  rehabilitation  laps 
over  into  the  hospital  treatment  and,  in  many  cases,  continues  for  an 

776 


CONSERVATION    AND    RECLAMATION    OF    THE    DISABLED      777 

indefinite  period  after  the  work  of  the  physician  has  been  completed. 
In  the  majority  of  cases  the  functional  re-education,  especially  the 
occupational  therapy,  can  be  made  so  practicable  that  it  will  dovetail 
with  the  rehabilitation. 

No  matter  how  honorable  the  wound  or  the  disease  that  incapaci- 
tates one,  no  man  likes  to  be  classed  as  ''disabled."  It  sounds  too 
much  like  being  ''put  on  the  shelf."  In  warfare  a  certain  percentage 
of  the  soldiers  is  bound  to  become  disabled;  very  few  need  remain  so. 
The  number  of  disabilities  sufficiently  serious  to  place  a  man  in  the 
discard  are  very  rare.  Practically  every  man,  no  matter  how  handi- 
capped he  may  be,  can  come  back.  In  fact  a  handicap  puts  more 
fight  into  a  man,  makes  him  strive  harder  than  ever  before,  and  results 
quite  often  in  his  making  good  to  a  greater  extent  than  if  he  had  never 
been  disabled. 

A  soldier  who  lost  both  legs  recently  said:  "Watch  me!  I  am  going 
to  make  good  with  both  feet."  And  he  has.  This  is  the  spirit !  Deter- 
mination and  grit — stick-to-it-iveness — are  the  qualities  which  every 
disabled  man  must  have  or  must  acquire  in  order  to  crawl  out  or  jump 
out  of  that  despised  category — the  crippled.  As  long  as  the  brain 
power  of  a  man  remains,  enabling  him  to  will,  to  choose  and  to 
persevere  in  effort,  he  is  a  long  way  from  being  a  permanent  cripple  or 
a  permanent  invalid. 

One  is  crippled  only  to  that  extent  to  which  he  allows  his  physical 
handicap  to  put  him  down  and  out.  If  he  ceases  to  be  an  economic 
factor  in  society — an  earning,  serving  unit — he  is  a  cripple.  But  if  in 
spite  of  his  handicap  he  overcomes  his  disability,  trains  himself  for 
work  and  becomes  a  productive  citizen  once  more,  he  is  no  longer 
classed  as  a  cripple. 

A  man  living  in  Kansas,  who  had  been  confined  to  his  bed  for  years, 
the  result  of  a  form  of  paralysis,  had  become  the  owner  and  superin- 
tendent of  a  large  publishing  business.  He  was  a  printer  formerly. 
When  asked  to  describe  how  an  invalid  in  his  condition  could 
accomplish  so  much,  he  said:  "I  am  not  an  invalid:  I  am  a  business 
man."  His  advice  was  that  no  matter  how  permanently  disease  ties 
up  the  body,  keep  the  mind  alert  and  active.  Make  it  work  for  you. 
Become  independent.  The  man  who  gives  up  to  his  disabilities  is  an 
"invalid;"  the  man  who  overcomes  them  is  a  force. 

As  a  nation  we  have  failed  to  teach  such  ideas  as  these  to  our  boys 
and  girls.  We  have  failed  to  help  our  citizens,  who  have  become  per- 
manently handicapped,  back  to  the  road  where  they  can  go  on  by  theii- 
own  initiative.  Too  often  the  disabled  man  has  passively  accepted 
his  fate,  and  his  friends  have  allowed  him  to  loaf,  or  to  accept  a  position 
where  no  incentive  or  future  existed,  such  as  the  proverbial  watchman. 
These  cripples  and  invalids,  seeing  the  money  made  by  professional 


778  INDUSTRIAL   MEDICINE    AND    SURGERY 

beggars,  have  even  drifted  into  that  class.  Every  nation  in  this  war 
has  awakened  to  the  fact  that  some  men  with  the  worst  kinds  of 
handicaps  have  become  successful,  useful  citizens.  Therefore,  why 
cannot  all  men,  and  especially  the  soldiers  disabled  because  of  war 
duty?  So  with  one  accord  these  nations  have  provided  the  means  of 
reclaiming  their  disabled  soldiers  and  of  giving  them  proper  training 
for  the  future  in  order  that  they  may  make  good  by  their  own  efforts. 

The  medical  department  of  the  United  States  Army  at  the  very 
beginning  of  this  war  made  plans  for  reclaiming  these  soldiers.  After 
other  wars  our  ^country  provided  soldiers'  homes  for  many  of  the 
disabled,  or  provided  pensions  to  help  the  crippled  man  eke  out  a  living 
at  some  mediocre  job.  The  soldiers  and  sailors  of  to-day  would  not  be 
satisfied  with  such  an  arrangement.  They  have  made  the  great  sacri- 
fice for  their  country  in  her  efforts  to  give  liberty  to  the  world.  Their 
country,  therefore,  must  provide  a  future  of  liberty  and  independence 
for  them.  Thus  the  government  has  evolved  excellent  plans  for  the 
physical  reconstruction  and  rehabilitation  of  disabled  soldiers  and 
many  are  receiving  the  benefits  thereof. 

There  is  another  soldier,  the  industrial  soldier,  the  soldier  of  the 
second  line  of  defense,  the  great  industrial  army  which  is  just  as 
essential  to  the  winning  of  any  war  as  is  the  military  army,  and  the  man 
who  becomes  disabled  and  wounded  without  the  glorification  that 
comes  from  such  wounds  when  received  on  the  battlefield.  Our  nation 
must  recognize  the  rights  of  these  disabled  men  from  industry  and 
provide  for  their  reconstruction  and  rehabilitation  likewise. 

PHYSICAL  RECONSTRUCTION  IN  THE  ARMY 

Before  discussing  the  reclamation  of  the  industrial  disabled  a  short 
resume  of  the  physical  reconstruction  work  in  the  army  will  give  a 
clearer  understanding  of  this  phase  of  medical  and  surgical  work  and 
its  relationship  to  complete  rehabilitation. 

It  has  been  difficult  to  make  many  of  our  people,  both  laymen  and 
physicians,  understand  that  physical  reconstruction  and  rehabilitation 
are  not  entirely  new  departures  in  the  treatment  of  sick  and  wounded. 
Boiled  down  to  simple  language,  however,  this  work  simply  means  that 
every  soldier  disabled  by  disease,  accident  or  war  wounds  must  be  cured 
and  made  fit  for  work.  To  accomplish  this  continued  medical  and 
surgical  care  must  be  given  until  his  disability  is  cured  or  the  maximum 
improvement  attained;  during  this  treatment  every  therapeutic 
adjunct  such  as  physiotherapy,  occupational  therapy,  curative  work 
and  any  other  agency  capable  of  hastening  recovery  must  be  employed; 
and  for  those  whose  handicaps  unfit  them  for  their  old  occupations 
some  form  of  vocational  training  must  be  given,  preferably  starting 
during  their  convalescent  days  and  continuing  as  long  thereafter  as  is 


CONSERVATION    AND    RECLAMATION    OF   THE    DISABLED      779 


necessary  to  refit  them  for  an  independent  existence.  All  of  this  is 
done  for  the  purpose  of  returning  every  disabled  soldier  to  civilian  life 
once  more  as  a  productive,  economic  unit  able  to  carry  on  by  his  own 
physical  powers,  or,  if  this  is  impossible  because  of  the  nature  of  his 
handicap,  then  by  his  mental  powers. 

Thus  it  is  evident  that  the  medical  and  surgical  treatment  involved 
in  reconstruction  is  not  new,  except  perhaps  that  the  value  of  certain 
therapeutic  adjunts  has  been  emphasized.  But  an  absolutely  new 
viewpoint  for  the  majority  of  physicians  and  for  the  laymen  in  general 
has  been  injected  into  the  practice  of  medicine,  namely — all  standards 
of  treatment  in  the  future  must  he  judged  by  the  economic  end-results 
obtained. 

It  was  realized  that  if  permanent  good  to  the  nation  was  to  result 
from  these  reconstruction  efforts  this  new  viewpoint  must  be  spread 
broadcast  throughout  the  land. 
Not  only  must  physicians  be 
imbued  with  these  principles, 
but  industry,  labor,  all  educa- 
tional agencies,  and  the  entire 
civilian  population  must  be 
made  copartners  in  this  great 
work.  Therefore,  the  Surgeon 
General's  OfSce  started  a  nation- 
wide educational  campaign  on 
the  reconstruction  and  rehabi- 
litation of  the  disabled  soldiers, 
constantly  pointing  out  the 
application  of  these  principles 
to  the  civihan  disabled.  This  publicity  work  was  greatly  enhanced 
by  similar  propaganda  sent  out  by  the  American  Red  Cross,  the 
Federal  Board  of  Vocational  Education,  the  American  Red  Cross 
Institutes  for  the  Crippled  and  for  the  Bhnd  and  by  several  states 
through  their  Departments  of  Industry  and  Labor. 

As  a  result  of  this  educational  work  the  entire  country  is  at  last 
awake  to  the  need  of  preventing  disabilities,  and  when  disabilities  do 
occur  to  the  necessity  of  reclaiming  the  victims  and  returning  them  to 
a  useful  existence  once  more.  To-day  it  is  possible  to  inaugurate 
reforms  which  will  correct  the  prodigality  of  our  nation  toward  human 
life  and  human  energy. 

Prior  to  this  war  the  army  regulations  required  that  all  disabled 
soldiers  becoming  unfit  for  full  military  service  should  be  discharged  at 
once.  In  other  words,  following  the  custom  in  vogue  in  many 
industries,  such  men  were  "scrapped"  with  very  little  thought, 
beyond  that  of  pension,  being  given  to  their  future.     In  May,  1918, 


Fig.  202. — By  means  of  the  whirl-pool 
bath,  a  cold,  clammy,  swollen  limb  becomes 
red  and  warm.  Frequent  repetition  helps 
re-establish  circulation.     {Carry  On.) 


780 


INDUSTRIAL   MEDICINE    AND    SURGERY 


the  reconstruction  policy  was  finally  approved  by  the  Secretary  of  War 
and  since  then  few  disabled  soldiers  have  been  discharged  until  "the 
most  complete  physical,  functional  and  mental  restoration  has  been 
attained,  or  is  possible  to  attain  when  the  nature  of  the  disabilities  are 
considered." 

Several   general   hospitals   have   been   utilized   to   carry   out  the 


m  -,3 


go 

,1^    S) 


ft  P 


s  6 


tn    CO  ^ 

n      <^      r~ 

.2    M  C 


CO  -?.  o 


intent  of  this  ploicy.  In  these  hospitals  thousands  of  disabled  soldiers 
have  been  treated,  or  are  now  under  treatment,  always  with  the  view 
of  accomplishing  their  complete  cure  or  their  maximum  improvement. 
Every  conceivable  type  of  disability  is  presented  including  many  cases 
with  multiple  disabilities.  They  can  be  grouped  under  the  following 
classes  according  to  their  frequency:  (1)  The  neuropsychiatric  cases; 
(2)  the  tuberculous;  (3)  the  orthopedic,  including  amputation  cases, 


CONSERVATION    AND    RECLAMATION    OF   THE    DISABLED      781 

and  the  deformities  following  infections,  scar  contractures,  certain 
fractures,  etc.;  (4)  the  cardiovascular;  (5)  the  general  medical  and 
surgical  cases;  (6)  the  blind  and  the  deaf. 

The  neuropsychiatric  patients  have  been  segregated  in  a  center 
consisting  of  a  hospital  and  barracks.  Here  it  has  been  found  that 
disciphne,  work,  play,  exercise,  hydrotherapy  and  intelligent  hand- 
ling combined  with  constant  effort  to  improve  their  morale  has  been 
the  best  means  of  restoring  these  soldiers  to  the  point  where  they  could 
be  discharged. 

The  tuberculous  have  been  sent  to  special  sanatoria  and,  in  addi- 
tion to  the  routine  treatment,  schools  and  shops  have  been  provided 
where  these  patients  could  receive  the  benefits  of  work  and  study  as 
soon  as  their  conditions  permitted.     Play,  work  and  physical  drillo 


KicnoM  Bep 


n 


mm 


Fig.    204. — Forty-seven   large   army   hospitals   are   now   carrying   on  physical 

reconstruction. 

have  been  found  the  most  excellent  adjuncts  toward  hastening  the 
cure  of  these  soldiers.  As  far  as  possible  the  work  has  been  made 
practical  with  a  view  of  improving  their  future  economic  state.  In- 
stead of  seeing  the  typical  group  of  hospitalized  tuberculous  patients 
one  finds  here  an  apparently  healthy  group  of  young  men  engaged 
in  many  different  activities.  Their  morale  is  good  and  as  a  general 
rule  they  are  anxious  to  remain  until  cured. 

Many  orthopedic  cases  are  under  treatment  at  Walter  Reed  Hos- 
pital. The  patients  with  amputations,  between  six  and  seven  hundred 
at  present,  are  fitted  as  soon  as  possible  with  their  artificial  appliances. 
For  a  certain  period  every  day  each  patient  receives  some  form  of  physio- 
therapy such  as  massage,  special  exercise  to  facilitate  motion  of  the 
stump;  also  occupational  and  mechanotherapy,  and  special  instruction 


782 


INDUSTRIAL   MEDICINE    AND    SURGERY 


in  the  use  of  his  artificial  member.  As  soon  as  his  general  condition 
permits  study  and  work  begins  in  the  schools  and  shops  adjacent  to 
the  hospital.  Excellent  educational  facilities  have  been  provided 
not  only  for  these  cases  but  for  all  other  convalescents.  There  are 
primary  classes  for  the  illiterates,  higher  grades  for  the  others  who 
were  never  permitted  to  complete  their  education,  and  college  courses 


for  the  boys  who  quit  the  universities  to  go  to  the  front.  Shorthand, 
typewriting,  bookkeeping,  telegraphy  and  many  other  commercial 
courses  are  available.  Those  who  have  lost  their  right  arms  are 
soon  taught  to  write  with  their  left. 

In  the  shops  these  amputation  cases,  patients  with  deformities, 
and  many  other  types  of  convalescents  receive  work  which  will  hasten 
their  functional  restoration  and  at  the  same  time  return  them  to  better 


CONSERVATION    AND    RECLAMATION    OP    THE    DISABLED      783 


Fig.  206. — Training  disabled  soldiers  in  art  work  and  sign  painting  during  their  con- 
valescent days  exemplifies  the  efforts  to  attain  an  economic  end-result. 


Fig.  207. — Motor  mechanics  and  other  forms  of  shop  work  hasten  the  restoration  of 
function  and  will  return  many  disabled  soldiers  to  better  jobs  in  ci%al  life. 


784 


INDUSTEIAL    MEDICINE    AND    SURGERY 


jobs  in  civil  life.  The  various  illustrations  give  an  excellent  idea  of 
these  different  therapeutic  adjuncts  which  help  in  the  physical  recon- 
struction of  these  disabled  soldiers. 

In  all  the  general  hospitals  where  the  different  types  of  special 

cases  are  collected  some  form  of  occupational  therapy,  curative  work 

and  study  and  a  certain  amount  of  vocational  education  is  being  given. 

The  re-education  of  the  bhnd  soldiers  forms  one  of  the  greatest 

examples  of  combining  medical  and  economic  treatment.     Previous 

to  the  war  there  were  some 
I    10  or   12   trades  and  pro- 
^  ,  \    fessions  that   the  majority 

of  blind  people  entered  in 
order  to  eke  out  a  liveli- 
hood, for  example  broom 
making,  piano  tuning,  bas- 
ketry, etc.  As  a  part  of  the 
plans  for  the  blind  soldiers' 
future,  industrial  engineers, 
working  under  the  direction 
of  Lt.  Colonel  James  Bord- 
ley,  have  made  extensive 
surveys  of  many  different 
industries  and  have  already 
found  208  different  occu- 
pations which  these  men 
can  perform  after  a  certain 
amount  of  training.  Men 
blinded  in  industry  in  the 
future  should  have  a  much 
happier  existence  than  has 
usually  been  afforded  them 
in  the  past  provided  this 
lesson  is  driven  home  (Fig. 
208). 

When  the  physical  re- 
construction is  completed 
these  variously  handicapped 
soldiers  are  discharged. 
The  compensable  cases 
whose  handicaps  make  it  necessary  to  learn  a  new  trade  or  profession, 
and  even  those  who  can  be  made  more  useful  citizens,  and  desire  the 
opportunity,  are  placed  under  the  Federal  Board  of  Vocational  Educa- 
tion to  whom  Congress  assigned  the  duty  of  completing  the  vocational 
rehabilitation  of  disabled  soldiers.     This  board  is  using  as  far  as 


is    taught    to 
dictaphone     some 
(Carry  On.) 


-Ti-aiiiinff    till"    liliiicl.      'r>')>i'\\  iitiii<i; 

all    blind    soldiers.     By  use  of  the 

become     expert    office    men. 


CONSERVATION    AND    RECLAMATION    OF   THE    DISABLED      785 

possible  the  existing  civilian  machinery  to  complete  this  phase  of  the 
work.  Trade  schools,  colleges,  and  all  kinds  of  industries  are  throwing 
open  their  doors  to  these  soldier  boys. 

By  co-operating  with  the  Department  of  Labor  all  reconstructed 
soldiers  are  being  placed  back  into  industry.  Supervision  to  see  that 
their  rehabilitation  is  completed  and  so  remains  devolves  upon  the 
War  Risk  Bureau  and  the  Federal  Board.  The  Civilian  Relief  Divi- 
sion of  the  American  Red  Cross  is  giving  valuable  assistance  in  this 
stage  of  the  work. 

The  problem  of  the  disabled  soldier  is  being  solved.  Our  greatest 
efforts  must  now  be  directed  to  secure  the  same  benefits  for  the  dis- 
abled from  industry. 

PHYSICAL  RECONSTRUCTION  IN  CERTAIN  INDUSTRIES 

Several  industries  with  comprehensive  systems  of  industrial  medi- 
cine and  surgery  have  been  practicing  the  best  form  of  reconstruction 
of  the  disabled  for  many  years,  although  their  work  was  not  so  desig- 
nated. In  fact  the  medical  staffs  of  these  concerns  have  developed 
a  more  practical  co-ordinated  system  of  reconstruction  than  any  yet 
devised  by  our  government  or  any  of  the  other  nations  in  this  war. 

The  terms  conservation  and  reclamation  more  clearly  define  the 
scope  of  these  efforts  in  industry  than  do  the  terms  physical  reconstruc- 
tion and  rehabilitation. 

But,  whatever  expressions  are  used  to  designate  this  work,  the  de- 
sired results  can  only  be  attained  by  a  completely  rounded  out  plan 
similar  to  that  adopted  in  these  industries.  It  includes:  (1)  Preven- 
tion of  disease  and  accident;  (2)  constant  health  supervision;  (3) 
adequate  medical  and  surgical  care  for  all  disabled;  (4)  proper  selec- 
tion of  work  according  to  the  physical  qualifications  of  each  individual, 
including  properly  chosen  new  work  for  the  handicapped  after  his 
recovery;  (5)  practical  vocational  training  in  the  plant  for  new  occu- 
pations when  the  disability  prevents  return  to  the  old  job;  (6)  and 
sufficient  compensation  for  the  disabled  man  and  his  dependents  to 
live  on  while  he  is  undergoing  reconstruction. 

Thus  those  surgeons  in  industry  who  have  returned  the  disabled 
employees  to  light  occupations  as  soon  as  possible  in  order  that  the 
work  could  help  restore  the  function  in  the  injured  member,  and  also 
to  assist  the  employee  to  regain  a  proper  mental  balance  once  more, 
have  been  practicing  the  best  type  of  physical  reconstruction.  Or 
what  better  example  of  reconstruction  can  one  find  than  that  of  the 
industry  which  sends  its  tuberculous  employee  to  a  sanatorium  until 
his  disease  is  arrested  and  then  allows  him  to  return  to  selected  work 
in  the  plant,  under  careful  medical  supervision,  until  his  disease  is 
cured  and  he  is  fully  restored  as  a  useful  member  of  society  once  more? 

50 


786  INDUSTRIAL   MEDICINE    AND    SURGERY 

When  a  man  loses  his  arm  or  some  other  member  and  is  unable 
to  return  to  his  old  job  many  of  these  concerns  give  him  an  opportunity 
to  learn  a  new  and  better  occupation  instead  of  relegating  him  to  the 
scrap  heap,  or  to  a  medicore  position  such  as  a  watchman.  Even 
employees  who  develop  heart  disease,  or  some  other  permanent  handi- 
cap the  result  of  disease,  are  often  trained  for  new  jobs  where  they  can 
still  be  efficient  without  further  jeopardizing  their  health. 

A  few  industries,  through  the  efforts  of  their  medical  staffs  have 
acquired  this  humane  attitude  toward  their  disabled  employees. 
Certainly  no  better  demonstration  of  practical  vocational  rehabili- 
tation can  be  found. 

Therefore,  industrial  medicine,  as  conceived  and  practiced  by  some, 
can  claim  the  honor  of  pioneering  in  this  field  of  reclamation.  Without 
the  war  many  years  would  have  elapsed  before  these  ideals  would 
have  received  general  recognition.  But  as  a  result  of  the  war  the 
entire  medical  profession,  industry  and  labor  and  society  in  general 
are  enthusiastically  grasping  this  new  principle — the  physical  recon- 
struction and  rehabilitation  of  disabled  men.  This  is  the  psychological 
moment  in  the  history  of  our  nation  to  extend  this  great  work  to  every 
employee,  yes,  to  every  individual  throughout  the  land. 

The  Usual  Method  in  Industry 

Unfortunately  only  a  relatively  small  number  of  industries  have 
the  enlightened  viewpoint  above  described.  The  majority  of  our 
employers,  great  and  small,  still  consider  the  human  machine  as 
something  to  use  to  the  utmost  for  gain;  to  conserve  its  powers  is  not 
their  responsibility.  Thus  in  spite  of  the  great  efforts  to  establish 
disease  and  accident  prevention,  adequate  medical  and  surgical  care 
and  various  reclamation  methods  we  still  have  and  will  continue  to 
have,  the  disabled  employee  in  our  midst.  The  man  whois  no  longer 
able  to  continue  at  heavy  work  because  of  a  damaged  heart  or  circu- 
latory apparatus;  the  man  who  develops  tuberculosis,  and,  even  though 
cured,  is  afraid  to  or  advised  against  returning  to  his  former  occupation, 
or  is  rejected  from  one  job  after  another  because  of  his  damaged  lung; 
the  epileptic  who,  to  safeguard  the  concern  against  possible  compensa- 
tion, is  fired  as  soon  as  his  condition  is  known;  the  men  with  hernias, 
with  flat  feet  and  many  other  anatomic  conditions  that  make  them 
inefficient,  as  well  as  the  armless  and  legless  and  others  seriously  handi- 
capped, the  result  of  injuries;  all  make  up  our  army  of  disabled  men. 
Every  year  adds  to  the  total  of  incompetents  who,  on  account  of 
disease  or  accidents,  are  prematurely  thrown  on  the  scrap  heap  be- 
cause their  handicaps  prevent  them  from  continuing  at  their  old 
occupations. 

As  already  stated  a  few  industries  salvage  these  disabled  and 


CONSERVATION   AND    RECLAMATION   OF   THE    DISABLED     787 

make  them  efficient  and  independent.  Some  industries  give  these 
employees  easy  jobs  where  they  can  make  a  hving.  But  the  very 
softness  of  the  job  robs  them  of  all  incentive,  and  the  bitterness  en- 
gendered from  dying  ambition  adds  to  their  incompetency,  so  that 
many  of  these  drift  on  into  the  scrap  heap.  Other  concerns  settle 
with  their  injured  workmen  when  they  are  legally  responsible  and  then 
dismiss  them.  Their  disabled,  for  whom  they  are  morally  responsible, 
are  scrapped  without  a  settlement.  These  men,  trained  for  certain 
occupations,  who  meet  with  permanent  handicaps,  are  the  waste  prod- 
ucts of  our  industrial  life.  Too  often  when  employed,  they  are  ineffect- 
ive because  they  are  thrown  into  the  job  without  considering  their 
physical  fitness  for  it.  Again  they  are  given  the  positions  of  watch- 
man, flagman,  messengers,  porters  and  similar  work  when,  with  proper 
training,  their  full  mental  energy  and  remaining  physical  capacities 
could  make  them  highly  efficient  in  much  more  gainful  vocations. 

The  most  unfortunate  group  of  disabled  men  are  those  who  cease 
to  be  employed  by  the  concern  responsible  for  their  disability.  Other 
employers  are  not  interested  in  them,  do  not  feel  responsible  for  them. 
They  drift  from  one  job  to  another,  constantly  dropping  to  a  lower 
scale,  until  finally  they  relinguish  all  effort  to  work.  These  make  up 
the  loafers,  the  beggar  on  the  corner,  the  shoestring  merchant  on  the 
street,  the  poor  physical  handicapped  and  mentally  debased  flotsam 
and  jetsam  of  our  civilization. 

Size  of  the  Problem 

In  the  army  several  million  dollars  have  been  set  aside  for  the 
reconstruction  and  rehabilitation  of  the  disabled  soldiers,  on  an  esti- 
mate that  there  would  be  approximately  50,000  of  these  men  each 
year  of  the  war  needing  reconstruction  and  20,000  of  these  would  need 
vocational  training.  Compare  with  this  the  meagre  appropriation  al- 
lowed for  the  reclamation  of  the  disabled  employees — the  soldiers  of 
our  great  industrial  army,  of  whom,  on  the  lowest  estimate,  there  are 
at  least  800,000  disabled  by  disease  and  accident  in  industry  every 
year  who  need  physical  reconstruction,  and  at  least  200,000  of  these 
need  training  for  new  and  better  occupations.  Fig.  209  graphically 
shows  the  size  of  the  problem  in  the  army  and  in  industry  and  its 
solution. 

If  the  casualty  list  from  industry  could  be  printed  every  day  in 
our  newspapers  the  people  of  this  country  would  be  appalled  at  its 
size.  In  one  year  from  accidents  alone  it  is  over  four  times  as  large 
as  the  entire  casualties  among  our  troops  on  the  battle  fields  in  Europe. 
We  have  no  record  to  show  the  number  who  are  killed  or  disabled 
as  the  result  of  occupational  diseases  and  diseases  partialty  traceable 
to  working  conditions  but  these  undoubtedly  are  even  more  shocking. 


788  INDUSTRIAL    MEDICINE    AND    SURGERY 

BY-PRODUCTS 

ZOOO.OOO     5^ldier^    irv    txjrc^pe 
2.00, 00  O    Pbdbled  ifv  6.^ed.r  1^  Wour\65;bydi5e(i.5e. 
50,  000   hxi^t  be  pKyJic^xlly  rec^rv^fmcted. 

3QOOQ006^  Ir\d\j^tria.l  5o\dm5  irv  iK<?  kdxj^the^ 

7)000.000  Rs^^bled  Wery ^e^r by  a.ccider\tib/ disease 

&00,000  JKovild  be  pKy^iC2ylly  recorvstructed 
?nO  nOO)  '^'^^^'^  ^*^  \)cc^).tior\6Jly  RetrAi'rved 

Git  out  ilto  Human  Scrap  Heap 
Salvage  ilio  Disablocl 

Conservo  ritimanLifo 
and  litmtan  Enor^y- 

Fig.   209. — Have  we  met  our  obligations? 

The  following  figures  furnished  by  the  Bureau  of  Statistics,  Depart- 
ment of  Labor,  are  very  instructive  in  this  connection : 

Estimated  number  of  persons,  ten  years  of  age  or  over,  gainfully  employed  in  the 

United  States  as  of  April  15,  1917 44,533,208 

Male 34,537,974 

Female 10,005,234 

(Include  employees,  employers,  farmers,  and  independent  workers.) 

Estimated  number  of  industrial  accidents  in  the  United  States  in  1917 903,000 

■Fatal 28,000 

Non-fatal  causing  disability  of  over  four  weeks 875,000 


CONSERVATION    AND    RECLAMATION    OF   THE    DISABLED      789 

Of  the  875,000  non-fatal  accidents  74,600  would  result  in  amputa- 
tion or  loss  of  use  of  some  member,  distributed  as  follows: 

Loss  of  1  eye  or  reduction  of  vision  to  3'io 5,700 

Loss  of  I  hand  or  arm . . .  .  : 2,880 

Loss  of  1  foot  or  leg ^ 1,220 

Loss  of  1  finger  or  part  of  finger 52,050 

Loss  of  two  or  more  fingers 9,100 

All  other  specific  injuries  (including  multiple) 3,580 

Total 74,600 

These  figures  do  not  include  the  great  number  of  accident  cases 
occurring  on  our  streets,  such  as  automobile  accidents.  These  vic- 
tims, often  very  poor,  are  carried  into  our  hospitals,  suffer  the  loss 
of  a  leg  or  an  arm  and  are  turned  out  surgically  cured  to  fend  for  them- 
selves. Many  of  these  are  far  from  economically  cured  and  make 
up  a  large  percentage  of  the  dependents  in  every  community. 

Two  years  ago  a  survey  of  all  crippled  individuals  in  Cleveland, 
Ohio,  was  made,  the  total  number  found  being  4815.  Of  this  number 
49  per  cent,  were  under  the  age  of  15  at  time  of  occurrence  of  disa- 
bility, while  43  per  cent,  were  between  the  ages  of  15  and  59  years,  or 
during  the  period  of  working  life.  Of  this  latter  group  40  per  cent, 
were  due  to  accident.  A  similar  survey  in  every  community  through- 
out the  land  would  undoubtedly  reveal  the  fact  that  industrial  acci- 
dents stand  second  as  the  cause  of  permanent  disabilities. 

At  this  time  comparison  between  the  casualties  from  war  and  the 
casualties  from  industry  is  the  most  striking  means  of  pointing  out 
the  size  of  our  civilian  disabled  problem.  Mr.  S.  S.  Riddle  has  just 
prepared  a  reconstruction  bulletin  for  the  Department  of  Labor  and 
Industry  of  the  State  of  Pennsylvania  in  which  he  makes  such  a  com- 
parison between  Canada  and  Pennsylvania  both  having  approximately 
the  same  population.  Mr.  Riddle  most  concisely  points  out  the  size 
of  this  problem  and  further  demonstrates  the  enormous  financial  cost 
resulting  from  accidents  in  his  state.     He  says : 

''The  army  of  employees  remaining  in  Pennsylvania  may  be  con- 
sidered as  six  times  as  great  in  number  as  the  army  Pennsylvania  will 
ultimately  put  in  the  field. 

"The  casualties  suffered  by  that  army  of  Pennsylvania  workers 
— estimated  to  average  continuously  3,000,000  during  the  two  j^ears 
and  a  half  from  January  1,  1916  to  July  1,  1918 — amounted  to  577,053, 
including  7575  fatalities,  according  to  accident  reports  submitted 
during  that  period  to  the  Pennsylvania  Department  of  Labor  and 
Industry.  An  accident  report  is  rendered  to  the  department  w^hen 
a  worker  is  killed,  or  disabled  for  a  period  of  two  days. 

''The  number  of  industrial  workers  injured  in  two  and  one-half 


790  INDUSTRIAL    MEDICINE    AND    SURGERY 

years  in  Pennsylvania  is  greater  than  the  army  that  either  Canada  or 
Pennsylvania  is  sending  against  Germany. 

"In  other  words,  if  the  number — not  the  percentage  of  the  total 
engaged — of  Pennsylvanians  injured  in  war  equals  in  two  and  one-half 
years  the  number  injured  in  the  industries  of  Pennsylvania  during 
the  same  period,  every  man  in  an  army  of  500,000  will  be  injured  once 
and  more  than  75,000  men  in  that  army  will  be  twice  wounded  during 
those  two  and  one-half  years. 

"Canada,  after  four  years  of  war,  has  had  approximately  50,000 
men  returned  as  unfit  for  further  military  service.  That  number, 
of  course,  does  not  include  the  total  number  of  men  who  have  been 
wounded  or  sick  and  who  have  recuperated. 

"A  vital  factor  in  a  comparison  of  the  disabled  in  war  with  the 
injured  in  industry  is  the  number  of  men  returned  as  unfit  for  army 
service  as  the  result  of  disease.  Mr.  T.  B.  Kidner  former  Vocational 
Secretary  of  the  Invalided  Soldiers'  Commission  of  Canada,  now 
associated  with  the  Federal  Board  for  Vocational  Education  of  the 
United  States,  in  an  address  on  'Vocational  Re-education  of  the  Handi- 
capped and  Incapacitated  in  Canada'  as  delivered  at  the  Eleventh 
Annual  Convention  of  the  National  Society  for  Vocational  Education 
at  Philadelphia  in  February,  1918,  cited  a  recent  official  statement 
made  in  England,  reporting  that  out  of  every  thousand  cases  of  disable- 
ment 547  are  cases  of  disease  and  453  are  cases  of  wounds  and  injuries. 

"If  that  ratio  holds  true  for  the  disabled  soldiers  returned  as  unfit 
to  Canada  and  to  Pennsylvania,  it  would  seem  to  indicate  that  only 
about  one-half  of  the  men  invalided  from  war  are  suffering  from 
wounds — but  every  man  in  the  list  of  industrial  accidents  reported  is 
actually  wounded. 

"Approximately  1200  of  the  50,000  disabled  soldiers  returned  to 
Canada  are  'amputation  cases'  or  soldiers  having  lost  one  or  more 
arms,  legs,  hands,  feet,  fingers  and  toes. 

"That  record  may  be  considered  with  the  statement  that  in  the 
industries  of  Pennsylvania,  during  the  period  of  only  two  years  and  a 
hah  from  January  1,  1916,  to  July  1,  1918,  there  have  been  3798 
industrial  'amputation  cases'  of  workers  having  lost  arms,  legs,  hands, 
feet,  fingers  and  toes. 

"On  the  basis  of  those  figures,  it  may  be  safe  to  assume  that  the 
total  number  of  amputations  suffered  by  men  in  Pennsylvania's  army 
in  the  field  of  war  will  be  considerably  less  than  the  total  number  of 
amputations  suffered  in  Pennsylvania's  industries  over  an  equal  period. 

"A  table  showing  the  dismemberments  and  loss  of  parts  suffered 
by  industrial  workers  in  Pennsylvania  from  January  1,  1916,  to  July  1, 
1918,  according  to  accident  reports  received  by  the  Pennsylvania 
Department  of  Labor  and  Industry  is  as  follows : 


CONSERVATION    AND    RECLAMATION    OF    THE    DISABLED      791 


Eyes 

Arms 

Hands 

Fingers 

Legs 

Feet 

Toes 

Year  1916 

366 
432 
359 

59 
81 
46 

105 

214 
136 

1,111 

749 
500 

111 

144 
69 

48 
112 

77 

87 

Year  1917 

81 

First  six  months,  1918 

f>8 

Totals 

1,157 

186 

455 

2,360 

324 

237 

236 

"On  the  other  hand,  the  amputations  in  warfare  are  probably  more 
serious  in  degree  than  the  amputations  in  industry.  According  to 
the  official  bulletin  of  the  Canadian  Department  of  Soldiers'  Civil 
Ee-estabhshment  for  March,  1918,  a  classification  of  the  amputation 
cases  in  the  Canadian  Army  shows  that  of  the  men  returned  to  Canada, 
328  had  lost  arms  and  723  had  lost  legs.  A  further  classification 
shows  that  virtually  twice  as  many  arm  amputations  were  made  above 
the  elbow  as  below  the  elbow  and  about  twice  as  many  leg  amputa- 
tions were  made  above  the  knee  as  below  the  knee. 

"After  almost  four  years  of  war,  with  an  army,  at  present,  of  between 
400,000  and  500,000,  Canada's  experience  shows  that  less  than  50 
soldiers  have  been  blinded.  It  has  been  stated  that  the  number  in 
the  Spring  of  1918  was  34. 

"In  the  shorter  period  of  only  two  and  one-half  years — from  January 
1,  1916,  to  July  1,  1918 — there  have  been  29  workers  blinded  through 
accidents  in  the  industries  of  Pennsylvania.  The  total  number  of 
eyes  lost  through  industrial  accidents  in  Pennsylvania  during  those 
two  and  one  half-years  is  1157. 

"Of  the  twenty-nine  men  blinded  by  industrial  accidents  in  Penn- 
sylvania during  two  and  one-half  years,  one  worker  also  lost  a  left  hand, 
one  a  right  arm,  and  one  both  hands  in  the  accidents  that  blinded 
them.  During  those  same  two  and  one-half  years,  five  workers  lost 
both  hands,  one  of  whom  also  lost  one  eye;  six  workers  lost  both  legs; 
three  workers  lost  both  feet;  four  workers  lost  both  an  arm  and  a  foot; 
five  workers  lost  both  an  eye  and  a  hand ;'  two  workers  lost  a  leg  and 
a  foot;  two  workers  lost  an  arm  and  leg  and  two  workers  lost  both 
arms. 

"During  the  two  and  one-half  years  from  January  1,  1916,  to  July 
1,  1918,  there  were  159,659  industrial  workers  injured  in  Pennsylvania 
and  disabled  for  a  period  exceeding  fourteen  days.  Those  workers 
received  workmen's  compensation  payments  as  provided  by  the  state 
law  and,  in  addition,  dependents  of  4636  workers  killed  in  industry 
likewise  received  workmen's  compensation  payments.  The  difference 
between  the  number  of  577,053  industrial  workers  reported  as  injured 
and  those  receiving  compensation  payments  represents  cases  where 
the  disability  did  not  exceed  a  period  of  fourteen  days. 


792  INDUSTRIAL    MEDICINE    AND    SURGERY 

"Workmen's  compensation  awarded  and  paid  for  fatalities  in 
Pennsylvania  from  January  1,  1916  to  July  1,  1918,  amounted  to 
$11,539,352.46  of  which  $1,393,616.76  had  been  paid  to  depend- 
ents. Payments  for  disability  cases  during  the  same  period  amounted 
to  $5,378,207.14.  The  gross  total  of  workmen's  compensation 
awarded  and  paid  in  Pennsylvania  for  fatal  and  disability  cases  from 
January  1,  1916,  to  July  1,  1918,  amounted  to  $16,917,559.60." 

Figures  from  other  states  would  indicate  that  considerably  over 
100,000,000  dollars  a  year  are  disbursed  in  payment  of  accident  com- 
pensation claims  throughout  the  United  States.  One-half  this  sum 
intelligently  spent  by  the  government  in  prevention  of  accidents  would 
reduce  the  number  of  persons  needing  physical  reconstruction,  and 
the  other  half  of  this  huge  amount  would  vocationally  train  and  other- 
wise reclaim  the  smaller  number  receiving  permanent  handicaps, 
as  well  as  pay  their  compensation.  It  must  be  remembered  that 
adequate  surgical  care  and  proper  training  will  always  reduce  the 
number  of  compensable  cases. 

No  less  an  authority  than  Dudley  M.  Holman,  recently  President 
of  the  International  Association  of  Industrial  Accident  Boards  and 
Commissions,  explains  the  size  of  the  problem  of  the  permanently 
disabled  worker,  and  the  value  of  prevention  as  a  means  of  reducing 
this  problem,  in  the  following  words: 

"It  is  a  very  conservative  estimate  to  state  that  annually  250,000 
workers  are,  under  present  conditions,  permanently  thrown  out  of 
employment  through  accident  or  preventable  disease  in  the  United 
States  alone.  These  men  and  women  must  be  supported  somehow. 
Part  of  them  receive  whole  or  partial  support  under  the  provisions  of 
the  workmen's  compensation  acts,  and  while  this  solves  in  whole  or 
in  part  their  individual  problem  of  existence,  it  does  so  in  most  states 
only  for  a  limited  period,  and  after  six  or  ten  years  of  idleness,  when 
their  compensation  ceases,  they  are  left  in  a  most  pitiful  condition. 

"Yet  there  are  a  few  of  these  men  and  women  who  could  be  put 
back  into  industry  and  have  a  place  found  for  them  where  they  could 
support  themselves  in  part  at  least. 

"This  economic  waste  caused  by  the  apparently  enforced  idleness 
of  this  vast  army  of  men  and  women  exceeeds  $100,000,000  a  year 
of  added  burden,  and  amounts  to  not  less  than  half  a  billion  dollars 
annually,  a  figure  that  is  constantly  being  increased  by  the  addition 
of  a  quarter  of  a  million  cripples  each  year. 

"Much  of  this  burden  is  primarily  borne  by  the  insurance  companies, 
but  they  pass  it  along  so  that  in  the  end  the  burden  falls  on  society 
in  general.  This  waste  is  a  by-product  of  industrial  inefficiency,  for 
by  prevention  of  accidents  and  disease  50  per  cent,  of  these  men  and 
women  would  never  become  disabled." 


CONSEEVATION    AND    RECLAMATION    OF    THE    DISABLED      793 


Interwoven  with  and  contributing  to  the  wastage  of  human  hfe 
and  human  energy  on  the  part  of  industry  and  of  society  is  the  inade- 
quate medical  care  so  often  afforded  these  victims  of  accident.  They 
are  admitted  to  our  wards  in  the  hospital  and  the  immediate  treatment 
or  operation  is  performed  properly  and  well.  This  is  followed  by  the 
daily  dressing.  For  the  remainder  of  the  day,  for  weeks  and  weeks 
to  come,  the  patient  is  left  to  his  own  devices.  Lying  there  in  idleness, 
with  worry  and  melancholy  his  chief  companions,  is  it  any  wonder 
that  traumatic  neuroses  develop?  Satisfied  with  a  good  surgical 
end-result,  as  usually  interpreted,  very  little  thought  is  given  to  the 
man's  future  economic  usefulness.     As  a  consequence  efforts  to  restore 


Fig.  210. — A  typical  scene  in  the  average  hospital.  Nothing  to  do  but  play  cards, 
checkers,  or  read  cheap  novels  for  weeks  upon  weeks  of  convalescence.  This  period 
should  be  utilized  to  improve  their  future  social  and  economic  conditions.  Suitable 
ward  occupations  will  hasten  recovery. 

function  in  the  disabled  member  receive  only  secondary  consideration. 
And  when  the  patient  must  finally  leave  the  hospital,  to  make  room 
for  other  unfortunates,  neither  the  surgeon  nor  the  insurance  company 
nor  the  responsible  employer  strive  to  place  him  in  a  position  where 
the  best  economic  end-result  can  be  attained  (Fig.  210). 

Every  surgeon  will  recognize  the  truth  in  the  following  statement 
made  by  a  layman,  Mr.  A.  Gwynne  James,  County  Court  Judge  under 
the  Workmen's  Compensation  Act,  in  Bathj,  England: 

''On  my  circuit  the  large  majority  of  injury  cases  arise  from  acci- 
dents in  mines  and  from  machinery,  and  the  lack  of  proper  and  ade- 
quate medical  treatment  and  training  is  simply  appalling.     There  is 


794  INDUSTRIAL    MEDICINE    AND    SURGERY 

practically  no  exception  to  the  following  routine :  On  the  workman  re- 
ceiving his  injury  he  is  sent  to  the  hospital,  where  he  receives  the  best  of 
treatment,  and  a  Hmb  is  amputated  or  other  treatment  given,  but  as 
soon  as  it  is  possible  to  remove  him  he  is  discharged  to  make  room,  for 
others.  He  then  becomes  an  out-patient  or  goes  home.  In  the  former 
case  (the  hospital  is  often  some  way  from  his  home)  he  attends  a  few 
times  for  dressings,  after  which  all  treatment  ceases;  in  the  latter  case  he 
is  attended  by  his  club  doctor,  often  a  young  and  inexperienced  medical 
practitioner,  who  has  had  no  communication  with  those  who  have 
treated  his  patient  at  the  hospital,  and  these  attendances  invariably 
cease  in  a  short  time,  and  from  then  the  injured  man  has  'to  fake  for 
himself.'  He  cannot  in  most  cases  carry  on  his  former  trade  and  has 
no  means  of  being  trained  to  another.  As  regards  artificial  limbs, 
although  I  have  had  hundreds  of  cases  before  me  involving  loss  of  a 
limb,  I  have  never  known  a  case  when  an  artificial  limb  has  been  sup- 
plied except  the  old-fashioned  leg  stump.  The  workman  does  not 
appreciate  or  understand  the  advantage  of  an  artificial  limb,  and,  if  he 
did,  has  not  the  means  to  buy  one.  Of  the  cases  which  come  before  me 
perhaps  the  most  numerous  and  difficult  to  deal  with  are  those  acci- 
dents which  result  in  a  permanently  stiff  limb.  The  insurance 
company  asks  the  judge  for  a  diminution  of  payment  to  the  workman 
on  the  ground  that  if  he  had  followed  the  doctor's  advice  the  limb 
would  not  have  become  stiff,  and,  therefore,  the  incapacity  to  work 
arises  from  the  negligence  of  the  workman.  The  treatment  advised  is 
generally  massage  and  certain  manual  exercises;  the  former  (in  most 
cases)  the  man  is  totally  unable  to  obtain,  either  because  there  is  no  one 
living  near  him  who  can  administer  it,  or  because  he  has  no  means  to 
pay  for  it;  as  regards  manual  exercises  there  is  no  institution  where 
they  can  be  given  and  where  he  can  be  instructed,  and  if  he  tries  to 
exercise  the  limb  himself  this  involves  in  most  cases  very  conside  'able 
pain,  especially  to  begin  with,  and  the  exercise  is  discontinued.  This, 
in  the  case  of  a  poor  and  ignorant  man,  cannot  be  held  to  be  negligence, 
especially  as  the  doctor  invariably  admits  that  had  the  patient  been  a 
well-to-do  one  he  would  have  advised  the  treatment  of  exercise  being 
done  in  the  first  instance  by  a  medical  man.  The  result  is  a  stiff  limb 
for  life,  a  continuance  of  weekly  payments  by  the  insurance  company 
(probably  for  life),  and  a  loss  to  the  country  of  the  man's  earn- 
ing powers. 

"Another  class  of  case,  occasioned  by  accident  arising  out  of  and  in 
the  course  of  the  workman's  employment,  is  stiff  limbs  arising  from 
traumatic  neurasthenia.  In  many  instances  under  proper  treatment 
the  neurasthenia  need  not  have  developed,  and  under  existing  circum- 
stances when  it  has  occurred  there  is  no  provision  of  any  kind  whatever 
for  medical  treatment  such  as  is  now  given  to  soldiers  suffering  from 


CONSERVATION    AND    RECLAMATION    OF    THE    DISABLED      795 

'shell  shock.'  I  have  only  dealt  with  a  few  instances  of  the  lack  of 
medical  and  orthopedic  treatment  of  our  injured  workmen  and  not 
with  his  re-education,  although  the  latter  is  of  signal  importance. 

"I  sincerely  trust  that  the  institutions  and  training  which  are  now 
being  founded  for  our  injured  soldiers  may  become  permanent  after 
the  war  and  available  to  the  English  workman.  As  regards  the  work- 
men's compensation  acts,  the  law  would  probably  have  to  be  amended 
by  introducing  a  slight  amount  of  compulsion  as  regards  treatment.  I 
do  not  think  there  would  be  much  difficulty  as  to  this;  for  example,  if 
the  workman's  doctor  and  the  insurance  doctor  agreed  that  a  certain 
treatment  was  necessary,  then  if  the  patient  refused  to  undergo  it  his 
weekly  pajnments  might  be  docked  or  varied. 

"Another  question  would  arise  in  respect  of  accidents  under  the 
above  acts  as  regards  the  cost  of  this  extra  treatment  and  on  whom  it 
should  fall.  In  my  opinion  this  cost  should  fall  mainly  if  not  entirely 
upon  the  insurance  companies,  although  in  the  case  of  an  injured 
workman  having  no  dependents  he  might  be  called  upon  to  pay  a 
small  amount  from  his  weekly  payments.  I  cannot  think  that  the 
insurance  companies  would  make  any  objection  to  this  course,  as  the 
extra  cost  to  them  would  be  more  than  covered  by  the  smaller  weekly 
payments  they  would  have  to  pay  owing  to  the  increased  power  of 
wage  earning,  and  the  earlier  date  at  which  their  Hability  to  make 
weekly  payments  would  cease.  Co-operation  and  help  should  be  ob- 
tained from  the  Trades  Unions,  without  whose  sympathetic  assistance 
the  success  of  the  workmen's  compensation  acts  would  not  have  been 
attained." 

Every  thoughtful  physician  and  surgeon  in  this  country  should  be 
stirred  to  the  utmost  endeavor  to  overcome  existing  conditions  by 
these  eloquent  words  from  the  pen  of  John  Mitchell: 

"  We  are  casting  valuable  workers  needlessly  on  the  scrap  heap.  In 
my  experience  as  chairman  of  the  New  York  Industrial  Commission, 
which  administers  the  workmen's  compensation  law,  I  am  brought 
face  to  face  every  day  with  the  tragic  consequences  of  our  failure  to 
make  some  provision  for  restoring  to  economic  usefulness,  self  assur- 
ance, and  renewed  interest  in  Hving,  those  victims  of  industry  whose 
injuries  have  maimed  or  disabled  them  beyond  ah  possibility  of  return- 
ing to  their  usual  occupations.  .  .  .  For  a  time  workmen's  compen- 
sation comes  to  the  aid  of  the  family.  Then  these  benefits  are  ex- 
hausted. The  little  savings  of  years  are  swallowed  up.  The  unfortu- 
nate man  is  entirely  cut  off  in  the  prime  of  manly  vigor  from  the  work 
he  knows  so  well  how  to  do.  He  sees  no  occupation  open  to 
him.  .  .  .  His  special  knowledge  of  working  processes  gone  to  waste, 
he  sinks  under  the  weight  of  his  misfortune  .  .  .  watching  .  .  .the 
black  shadows  of  destitution  fall  over  his  home." 


796  INDUSTRIAL    MEDICINE    AND    SURGERY 

The  Solution  of  the  Problem 

The  accident  cases — the  armless,  the  legless  and  the  blind — form 
the  most  spectacular  group  of  those  needing  physical  reconstruction. 
But  those  employees  suffering  from  "invisible  wounds" — the  tuber- 
culous, the  heart  case,  the  nephritic,  the  mental  defective  and  the 
victims  of  occupational  diseases — demand  the  same  care. 

The  problem  of  the  disabled  from  industry  can  only  be  solved, 
however,  by  considering  every  angle  of  human  conservation  and 
reclamation.  It  involves  more  than  the  physical  reconstruction  and 
vocational  training. 

Every  year  recently  has  witnessed  the  enactment  of  laws  by  the 
different  states  tending  to  meet  some  portion  of  this  problem.  But 
these  laws  show  a  woeful  lack  of  intelligent  understanding  of  the 
exigency  and  are  very  inadequate.  Proof  of  this  statement  has  just 
been  furnished  in  the  pages  dealing  with  the  size  of  this  problem  as  it 
confronts  us  to-day  after  several  years  of  legislative  effort. 

The  first  real  advance  in  labor  legislation  in  this  country  was  the 
enactment  of  certain  laws  regarding  industrial  sanitation  and  the  es- 
tablishment of  state  factory  inspectors  in  practically  every  state. 
These  have  been  followed  by  acts  concerning  hours  of  labor,  employ- 
ment of  women  and  children,  periodical  examinations  for  occupational 
diseases  and,  in  38  states,  employees'  compensation  acts.  The  Federal 
government  has  passed  similar  laws  for  the  government  employees. 
At  present  there  is  a  bill  before  Congress  for  the  vocational  rehabilita- 
tion of  industrial  cripples.  The  trouble  with  all  this  legislation  and 
the  reason  that  it  has  not  been  more  successful  is  this  piecemeal  method 
of  meeting  the  requirements. 

Certainly  the  time  is  ripe  for  uniform  labor  legislation  which  will 
adequately  solve  the  problems  of  conserving  human  life,  reclaiming  the 
disabled,  sufficient  compensation  for  disabilities  sustained,  insurance 
against  sickness,  old  age,  and  unemployment,  and  better  living  and 
working  conditions. 

Instead  of  Congress  enacting  another  law  applying  to  only  a  small 
angle  of  this  great  question  it  would  be  much  wiser  for  it  to  appoint  a 
commission,  and  provide  sufficient  funds,  in  order  that  the  whole 
situation  could  be  studied  and  a  standard  law  submitted  to  the  Federal 
and  state  governments  which  would  furnish  a  comprehensive  solution 
of  the  whole  problem. 

Such  a  law,  couched  in  simple  but  unmistakable  language,  and 
enacted  in  every  state,  must  provide  for  the  following: 

1 .  Prevention  of  Disease  and  Accidents. — All  possible  methods  of 
preventing  occupational  diseases  must  be  standardized  and  their  use 
made  compulsory. 

Protection  of  fellow  employees  from  communicable  diseases,  in- 


CONSERVATION    AND    RECLAMATION    OF    THE    DISABLED      797 

eluding  the  discovery  of  such  diseases,  must  be  provided,  as  well  as 
adequate  supervision  of  health  in  order  to  detect  all  disease  in  its 
incipiency. 

The  effective  accident  prevention  measures  now  being  used  in 
many  industries  must  be  applied  to  all. 

Provisions  must  be  made  to  include  the  farmer,  the  small  employer, 
the  employer  of  domestic  help,  and  every  community  activity  in  the 
scope  of  this  law. 

Above  all  it  must  provide  for  better  living  and  housing  conditions, 
better  working  conditions,  shorter  hours  of  labor  and  better  wages  so 
that  "the  gaunt  spector  of  poverty  will  be  removed  from  the  doors  of 
those  who  toil,  and  will  give  to  them  a  part  of  the  day  for  rest  and 
recreation  in  order  to  repair  the  bodily  wastes  that  sap  the  energy  and 
consequently  reduce  their  output  through  fatigue  and  overwork." 

2.  Adequate  Medical  and  Surgical  Care. — It  must  provide  for  the 
best  and  immediate  medical  and  surgical  care  for  every  sick  or  injured 
employee.  Whenever  occupational  conditions  are  responsible  for 
the  sickness  or  injury  the  employer,  should  furnish  this  care. 

Adequate  care  must  be  clearly  defined  and  must  include  every 
therapeutic  adjunct  which  will  enable  the  physical  reconstruction, 
the  functional  re-education  and  the  maximum  restoration  to  useful 
employment  of  every  disabled  individual. 

State  and  community  hospitals,  convalescent  centers,  and  human 
repair  shops  must  be  provided  where  this  treatment  can  be  furnished 
under  proper  environment  and  supervision. 

Suitable  artificial  appliances  and  training  in  their  use  must  be 
considered  a  definite  part  of  treatment.  No  longer  should  such  an 
important  branch  of  medicine  and  of  social  economy  be  left  to  the 
uncontrolled  commercial  interests  of  the  country. 

3.  Training  and  Emplo3anent. — The  recent  provisions  for  the 
vocational  rehabilitation  of  disabled  soldiers  and  sailors  and  their 
return  to  civil  employment  must  be  extended  to  the  disabled  in 
industry. 

Centers  must  be  provided  in  every  state  where  disabled  men  made 
unfit  by  disease  or  accident  for  their  usual  vocations  can  be  retrained 
for  useful  employment. 

Federal,  state  and  local  employment  agencies  must  be  provided 
for  the  intelligent  placing  of  these  men  in  suitable  occupations. 

Employers  must  be  required  to  train  their  disabled  employees  for 
better  or  just  as  good  positions  as  they  formerly  held  instead  of 
relegating  them  to  the  usual  jobs  for  cripples  such  as  watchman, 
messengers,  etc. 

4.  Compensation  and  Insurance. — Thirty-eight  states  have 
already  enacted  employees'  compensation  laws.     None  of  these  covers 


798  INDUSTRIAL   MEDICINE    AND    SURGERY 

all  employments;  the  amount  of  compensation  paid  for  disabilities 
has  a  very  wide  range;  and  the  methods  of  insuring  the  risks 
and  administering  the  acts  differ  materially  in  the  various  states. 
The  crying  need  is  for  a  uniform,  standardized  compensation  law  in 
every  state. 

Insurance  against  sickness,  accidents,  invalidity,  unemployment 
and  old  age  must  be  provided  as  a  definite  part  of  a  conservation  and 
reclamation  program. 

5.  Machinery  for  Carrying  Out  the  Act. — Each  state  should  have 
a  central  administrative  body  with  sufficient  administrative  and  police 
powers  to  execute  the  intentions  of  the  Act. 

Health,  sanitation,  food,  housing,  employment,  education,  insur- 
ance and  both  industry  and  labor  should  be  represented  on  this 
central  commission.  As  far  as  possible  these  should  be  removed  from 
the  appointive  realm  of  politics  and  should  be  considered  honor 
positions.  The  activities  of  the  different  state  departments  should 
be  co-ordinated  so  as  to  avoid  the  present  duplication  and  inefficiency 
existing  in  the  Federal  and  state  governments. 

Qualified  medical  men  and  laymen  must  be  appointed  to  supervise 
every  angle  of  this  work  including  even  the  medical  and  surgical 
treatment  afforded  the  disabled,  the  type  of  health  supervision  mam- 
tained,  as  well  as  the  living  and  working  conditions  of  all  coming  under 
the  Act. 

6.  Remedial  Measures  for  Existing  Conditions. — ^Laws  requiring 
compensation  for  injuries  without  providing  for  accident  prevention 
have  proven  how  wasteful  partial  legislation  to  meet  a  given  situation 
can  be.  Therefore,  remedial  legislation  for  the  purpose  of  removing 
or  correcting  all  things  which  prevent  the  complete  fulfillment  of  the 
proposed  law  is  essential. 

No  longer  should  inadequate  medical  and  surgical  care  be  tolerated 
or  protected  by  the  unwritten  laws  of  the  profession  generally  included 
under  the  term  medical  ethics. 

Those  hospitals  notorious  for  their  lack  of  high  standards  and 
responsible  for  many  a  case  of  permanent  disability  must  be  abolished. 

Patent  medicines,  fake  appliances,  and  quackery  of  every  form, 
acting  as  a  snare  and  delusion  for  millions  of  employees,  must  be 
eradicated. 

Child  labor  and  every  other  form  of  exploitation  of  labor  must 
cease. 

Above  all  such  a  law  must  be  absolutely  just,  based  upon  the 
rights  of  both  industry  and  labor,  and  tending  to  weld  into  a  close 
partnership  those  who  employ  and  those  who  must  work.  The  new 
viewpoints  gained  from  the  sacrifices  of  this  war  must  lead  our  country 
into  a  true  democracy  with  equal  rights  for  all. 


CONSERVATION    AND    RECLAMATION    OF   THE    DISABLED      799 

It  is  not  to  be  expected  that  these  great  social,  economic  and  indus- 
trial problems  will  be  solved  immediately.  Great  progress  has  been 
made  during  the  short  time  we  have  been  in  the  war.  But  years  of 
effort,  propaganda  and  example  are  yet  required  before  these  ideals 
can  be  attained.  With  immigration  ceasing  to  a  large  extent  and  with 
the  increased  demands  upon  our  industrial  resources  it  will  be  necessary 
for  the  nation  to  conserve  its  man-power  if  we  intend  to  maintain 
America's  economic  supremacy  and  to  take  our  rightful  place  in  the 
great  commercial  struggle  confronting  the  world. 

Industrial  medicine  has  already  blazed  the  trail  in  this  the  greatest 
conservation  movement  ever  inaugurated.  It  has  played  a  most 
important  part  in  helping  win  the  war  by  maintaining  the  health 
and  efficiency  of  our  second  line  of  defense — the  industrial  army.  It 
must  now  forge  ahead,  extending  its  principles  to  every  industry  in 
every  community  of  the  land.  It  must  now  become  the  pioneer  move- 
ment for  the  socialized  medicine  of  the  future. 

With  a  broadened  vision  and  a  greater  capacity  for  service  let  us 
strive  for  this  ideal — Human  Conservation  and  Reclamation  of  all 
Disabled. 


BIBLIOGRAPHY 

A  very  complete  bibliography  on  Industrial  Medicine  and  Surgery  prior  to 
1916  can  be  obtained  from  the  following  sources: 

United  States  Department  of  Labor,  Bureau  of  Statistics.  Books  and  period- 
icals on  accident  and  disease  prevention  in  industry,     Washington,  1915. 

KoBER  &  Hanson.  "Diseases  of  Occupation  and  Vocational  Hygiene," 
Philadelphia,  1916. 

SiE  Thomas  Oliver.  "Occupational  Diseases  from  Social,  Hygienic,  and 
Medical  Points  of  View,"  Cambridge  University  Press,  1916. 

The  following  bibliography  includes  practically  all  the  articles,  reports,  special 
bulletins  and  transactions  published  on  this  subject  since  1916.  The  names  of  all 
contributors  are  not  included,  in  this  list  as  their  articles  appear  in  the  various 
reports  and  transactions  referred  to. 

Adamson,  R.  a.  E.     Workshop  for  the  handicapped.     Survey,  New  York,  1916, 

xxvi,  392-393. 
Adler,    Eleanor.     An  experimental  employment  bureau  for  cripples.     Work 

gives  the  afflicted  a  new  lease  on  life.     Changed  attitude  on  the  part  of 

employers.     Modern   Hospital,  Chicago,   1918,  xi,   402-405. 
Albaugh,  R.  P.     Health  protection  in  industries  manufacturing  war  materials. 

Ohio  Public  Health  Journal,  Columbus,  1917,  viii,  300-302. 
.     Peculiar  poisoning  in  construction  camp  (carbon  monoxide).     Ohio  State 

Board  of  Health  Bulletin,  Columbus,  1917,  viii,  195-200. 
Alberti,  E.  J.  H.     Twee  gevallen  van  schadelyke  werking  door  den  electrichen 

stroom.     Nederlandsch    Tydschrift   voor    Geneeskunde,    Amsterdam,  1918, 

i,  232-234. 
Albrecht,  a.  E.     Industrial  accidents  and  the  education  of  immigrants.     School 

and  Society,  New  York^  1917,  vi,  652. 
Alexander,    M.   W.     Measuring  the  workman's  physical  fitness  for  his  job. 

Industrial  Management,  New  York,  1917,  lii,  493-502. 
.     The   physician   in   industry.     Dominion    Medical    Monthly,    Toronto, 

1916,  xlvi,  97-105. 
-.     Health  supervision  in  Industry — Conference  Board  of  Physicians   in 


Industrial  Practice,   1917. 
Allport,  F.     State  legislation  concerning  shop  lighting,  shop  accidents,  shop 

conditions,   the   common  towel,   etc.     Ophthalmology,    Seattle,    1916-1917, 

xiii,  48-117. 
Amar,  Jules.     Organisation  physiologique  du  travail.     Paris,  1917. 
.     The  physiology  of  industrial  organization  and  the  re-employment  of  the 

disabled.     Translated  by  Bernard  Miall.     London,  1918. 
Andrews,  J,  B.     Industrial  hygiene  and  health  insurance.     American  Journal  of 

Public  Health,  Concord,   1916,  vi,  959-963. 
Andrews,  J.  B.     New  Federal  workmen's  compensation  law.     Survey,  New  York, 

1916,  xxxvi,  617. 
.     Physical  examination  of  employees.    American  Journal  of  Public  Health, 

Concord,  1916,  vi,  825-829. 
.     A  timely  brief  for  health  insurance.     Boston  Medical  and  Surgical 

Journal,  1916,  clxxv,  539. 
Andrus,  C.  S.     The  responsibility  of  industrial  boards  to  employer  and  employee 
SI  801 


802  INDUSTRIAL    MEDICINE    AND    SURGERY 

as  influenced  by  the  opinion  of  the  medical  officer.     Journal  of  the  American 

Medical  Association,  Chicago,  1918,  Ixxi,  508-511. 
Anthony,   F.  W.     Industrial  health  legislation.     Boston   Medical  and  Surgical 

Journal,  1916,  cLxxv,  911-913. 
Appelbaum,    S.    J.     Compulsory    health    insurance.     Journal    of    the  American 

Medical  Association,  Chicago,  1917,  Ixviii,  1338-1339. 
Armstrong,  D.  B.     Social  aspects  of  industrial  hygiene.     American  Journal  of 

Public  Health,  New  York,  1916,  vi,  546-553. 
Ashe,  S.  W.     Organization  in  accident  prevention.     New  York,  1917. 
Atherton,  Sarah  H.     Survey  of  wage-earning  girls  below  16  years  of  age  in  Wilkes- 

Barre,  Pa.     Nail  Consumer's  League,  New  York,  1915. 

B.,  A.     Lo  stabilimento  tipolitografico  Antonio  Vallardi  nei  rapporti  della  igiene 

e  della  sicurezza.  Rivista  di  Ingegneria  Sanitaria,  Torino,  1916,  xii,  1,  13. 
Bacon,  J.  E.     Traumatic  hernia.     Southwestern  Medicine,  El  Paso,  1917,  i,  No.  9, 

p.    9-12. 
Baldy,   John  M.     What  constitutes  reasonable  surgical,  medical  and  hospital 

services  under  compensation  act.      (Second  Conference  Industrial  Physicians, 

Harrisburg,  1916.) 
Baker,  V.  C.     Dusty  occupations.     Journal  of  the  American  Medical  Associa- 
tion, Chicago,  1916,  Ixvi,  1453-1456. 
Bangert,   George   Schuyler.     Occupational  mercury  poisoning.     New  York, 

1918.     Reprinted  from  New  York  Medical  Journal,  June  22,  1918. 
Bargeron,   L.     L'hygiene    dans   la   reconstruction   des   usines   apres   la   guerre. 

Annales  d'Hygiene  Publique  et  de  Medicine  Legale,  Paris,  1916,  xxvi,  257-273, 

321-345;  1917,  xxvii,  213;  xxviii,  57. 
Bargoni,  Foscolo.     The  insurance  of  the  disabled  against  industrial  accidents. 

In:  Inter- Allied  Conference  on  the  After-care  of  Disabled  Men.     Pi,eports, 

London,    1918,    p.    71-82. 
Baskerville,  C.     The  American  chemist  and  occupational  diseases.      Medicine 

and  Surgery,  St.  Louis,  1917,  i,  767-771. 
.     Occupational  diseases  in  the  chemical  trades.     Journal  of  Industrial  and 

Engineering  Chemistry,  Easton,   1916,  viii,   1054. 
Batjvallet,  H.     Note  sur  un  nouveau  modele  de  casque  recepteur  pour  radio- 

telegraphie  et  telephonie.     Bulletin  de  I'Academie  de  Medicine,  Paris,  1917, 

Ixxviii,  101-103. 
Bentley,  J.  R.     Welfare  work  of  Montgomery  Ward  &  Company.     Journal  of 

Ophthalmology,  Otology  and  Laryngology,  Lancaster,  1917,  xxiii,  529-545. 
Beyer,  David  Stewart.     Accident  prevention.     Annals  of  the  American  Academy 

of  Political  and  Social  Science,  Concord,  1917,  Ixx,  238-243. 
Billings,    Frank.     The   program    for  the  physical   reconstruction  of  disabled 

soldiers,  Jour.  A.  M.  A.,  July  1,  1918. 
BiRKS,  M.     Mine  accidents  at  Broken  Hill  and  their  treatment  at  the  Broken  Hill 

and  district  hospital.  Medical  Journal  of  Australia,  Sydney,  1918,  i,  507-510. 
Blanchard,  R.  H.  Liability  and  Compensation  insurance.  New  York,  1917. 
Block,  E.     Resume  of  health  conditions  of  a  modern  department  store.     New 

Orleans,  Medical  and  Surgical  Journal,  1917-18,  Ixx,  724-733. 
Bloedorn,  W.  a.     Studies  of  industrial  accidents  which  occurred  in  the  Navy 

Yard  at  Washington,  D.  C.     U.  S.  Naval  Medical  Bulletin,  Washington,  1916, 

X,  585-625. 
Bloodgood,   J.   C.     How  the  industrial  surgeon  can  best  co-operate  with  the 

government  during  the  war.     Southern  Medical  Journal,  Birmingham,  1918,^ 

xi,  543. 


BIBLIOGRAPHY  803 

Bloodgood,    J.    C.     Medical  preparedness  in  the    great   drive  for  democracy-. 

Southern  Medical  Journal,  Birmingham,  vol.  x,  No.  7,  544-546. 
BOLAND,  F.  K.     Traumatic  rupture  of  viscera  without  external  wound.     Journal 

of  the  Medical  Association  of  Georgia,  Augusta,  1917-1918,  vii,  74-78. 
Bonnier,    J.  W.     Statistique  de  I'hygi^ne  professionnelle.     Bulletin    Manitaire, 

Montreal,    1916,    xvi,    81-86. 
BoRDLEY,  James,  Jr.     The  re-education  of  the  blind.     Jour.  A.  M.  A.,  July  7, 1918. 
Borne,    and    Kohn-Abrest.     Le    bouton    d'huile    des  ouvriers  metallurgistes. 

Revue  d'Hygiene  et  de  Police  Sanitaire,   Paris,    1916,   xxxviii,    1077-1093. 
Bouquet,  H.     Le  travail  industriel  des  femmes  et  I'Acad^mie;  la  propagande 

francaise  par  les  medecins.     Monde  medical,  Paris,  1916-17,  xxvi,  170-174. 
Bowers,  A.  P.     Tuberculosis  as  it  affects  the  worker.     Monthly  Bulletin  of  the 

Pennsylvania  Department  of  Labor,  Harrisburg,  1917,  iv,  106-108. 
Brock,  L.  G.     The  re-education  of  the  disabled.     Nineteenth  Century,  New  York, 

1916,  Ixxx,  822-835. 
Brocx,    D.     De   organisatie   van   het   reddingwezen   in   onze   steenkolenmijnen. 

Reddingwezen,  Rotterdam,  1917,  vi,  203;  231. 
Bromberg,   R.     (Occupational  diseases  and  their  social  importance.)     Medisch 

Weekblad,  Amsterdam,  1916-17,  xxiii,  205,  217,  231,  241,  253,  265,  277,  289, 

301,  313,  325. 
Bulletins.     National    Founders    Association    on    Safety    and    Sanitation.     West 

Lynn,  Mass. 

Carmichael,  H.  B.  The  method  of  examination  and  results  in  sight,  hearing  and 
colour  vision  for  one  year  on  the  Grand  Trunk  Railway  system.  Canadian 
Medical  Association  Journal,  Toronto,  1916,  vi,  210-227. 

California.     Report  of  Industrial  Accident  Commission — 1915  to  1916. 

Gary,  Harold.  Keeping  employees  happy.  Music,  rest  and  recreation  contrib- 
ute to  the  success  of  a  button  factory  and  the  content  of  its  employees. 
Modern  Hospital,  St.  Louis,  1917,  viii,  232. 

Cause  and  prevention  of  furunculosis  and  wound  infection  among  machinists. 
Ohio  Public  Health  Journal,  Columbus,  1918,  ix,  145-152. 

Certifying  factory  surgeons.      British  Medical  Journal,  London. 

Chaney,  Lucian  W.  and  Hugh  S.  Hanna.  Accidents  and  accident  prevention 
in    machine    building.     Washington,     1917. 

.     Can  serious  industrial  accidents  be  eliminated?     Monthly  Review  of  the 

U.  S.  Bureau  of  Labor  Statistics,  Washington,  1917,  v,  201-216. 

The  safety  movement  in  the  iron  and  steel  industry   1907  to   1917. 


Washington,  1918.     (U.  S.  Department  of  Labor.     Bureau  of  Labor  Statis- 
tics.    Bulletin  No.  234.) 
Chubb,  Irene  Sylvester.     Some  problems  of  the  partially  disabled,  in  war  and 

industry,    American  Labor  Legislation  Review,  New  York.,  1918,  viii,  294-305. 
CiAMPOLiNi,  A.     Rischio  professionale  e  rendimento  utile  degli  operai  invalidati 

che  si  riadattano  al  lavoro.     Ramazzini,  Firenze,  1916,  x,  137-160. 
Clark,  Lindley  D.     Workmen's  compensation  legislation  of  the  United  States 

and  foreign  countries,  1917  and  1918.     Bulletin  of  the  United  States  Bureau  of 

Labor  Statistics,  No.  243,  Washington,  1918. 
Clark,  W.  I.    Adjustment  of  physical  defectives  to  employment.     Boston  Medical 

and  Surgical  Journal,   1917,  clxxvii,  578-580. 
.     Medical  supervision  of  factory  employees.     Journal  of  the  American 

Medical  Association,  Chicago,   1917,  Ixviii,   5-8. 
.     Nail  puncture  wounds  of  the  foot.     Boston  Medical  and  Surgical  Journal, 


Apr.,  1917. 
—     Physical  examination  and  medical  supervision  of  factory  employees. 


804  INDUSTRIAL    MEDICINE    AND    SURGERY 

In:  Proceedings  of  the  Conference  of  Social  Insurance,  1916,  Washington, 

1917,   p.   317-326;   335-347. 
Clark,  W.  I.     The  protection  of  the  health  of  the  worker  in  war.     Journal  of  the 

American  Medical  Association,  Chicago,  1917,  Ixix,  1124-1129. 
Clegg,  J.  G.     Ophthalmic  occupational  affections  as  described  by  Prof.  Ramaz- 

zini,  of  Modena  and  Padua,  at  the  end  of  the  seventeenth  century.  Ophthal- 
moscope, London,  1916,  xiv,  290-300. 
Clewell,  C.  E.     Natural  lighting  in  shop  work  spaces.     Metal  Worker,  Plumber 

and  Steam-fitter,  New  York,  1918,  Ixxxix,  162-166. 
Clinical    study    of    lead,    turpentine,    and   benzine    poisoning    in   402   painters. 

Monthly  Labor  Review,  Washington,  1919,  viii,  No.  3,  p.  227-229. 
Close,  C.  L.     Economic  saving  of  human  resources.     Scientific  Monthly,  Garri- 
son, N.  Y.,  1917,  iv,  428-437. 
Clough,  F.  E.     From  kindergarten  to  library.     Welfare  work  of  the  Homestake 

mining  company,  Lead,  S.  D.     Modern  Hospital,  St.  Louis,  1917,  viii,  74-75. 
CoBURN,    C.    O.     Industrial   medicine.     Transactions    of   the    New    Hampshire 

Medical  Society,  Concord,   1918,  cxxcii,  85^100.     , 
CoLCORD,  A.  W.     Hernia;  should  it  be  classed  as  a  compensable  injury  or  a 

disease?     Pennsylvania    Medical    Journal,    Athens,    1917-18,  xxi,  672-684. 
CoLLis,  E.  L.     The  protection  of  the  health  of  munition  workers;  with  special 

reference  to  the  work  of  the  health  of  munition  workers  committee.     Journal 

of  State  Medicine  London,  1917,  xxv,  203-213. 
Compulsory   health  insurance.     Journal  of  the  American   Medical  Association, 

Chicago,  1917,  Ixviii,  292. 
CoNCTJLMER,  P.     Neurosi  traumatiche.     Rivista  Medica,  Milano,  1916,  xxiv,  17. 
Cottingham,  C.  E.     Occupational  neuroses;  report  of  seven  cases  of  a  new  type. 

Journal  of  the  Indiana  State  Medical  Association,   Fort  Wayne,   1918,  xi, 

297-302. 
Cotton,  F.  J.     A  consideration  of  workingmen's  accident  and  sickness  insurance 

in  their  relation  to  the  medical  profession.     Boston   Medical  and  Surgical 

Journal,   1916,  clxxv,  893-897. 
CouiLLARD,    E.     L'inspection    medicale    de    I'industrie.     Bulletin    medical    de 

Quebec,  1916,  xviii,  145-158. 

— .     Bulletin  Sanitaire,  Montreal,  1916,  xvi,  92-103. 

Crandall,  E.  p.     Industrial  welfare  nursing.     Public  Health  Nurse  Quarterly, 

Baltimore,  1916,  viii,  No.  2,  p.  32-47. 
Cronin,   Herbert  J.     Administration  of  the  Workingmen's  compensation  act 

by  the  city  of  Cambridge,   Massachusetts.     Boston   Medical  and  Surgical 

Journal,    1916,   clxxv,    906-911. 
.     The  establishment  of  a  first-aid  hospital  in  industry.     Boston  Medical 

and  Surgical  Journal,  1917,  clxxvii,  580-583. 

The    physician    and    the    prevention  of  industrial  accidents.     Boston 


Medical  and  Surgical  Journal,  1916,  clxxiv,  870-874. 

Crosby,  John  C.  Workingmen's  compensation  act.  Boston  Medical  and 
Surgical  Journal,  1916,  clxxv.  883-892. 

Crown  Mines,  Limited.  Annual  report  of  the  Chief  Medical  Officer,  1916. 
Crown  Mines,  1917. 

Crum,  F.  S,  Facts  showing  the  correlation  between  tuberculosis  and  industry. 
Journal  of  the  Medical  Society  of  New  Jersey,  Orange,  1918,  xv,  181-183. 

.  The  mortality  from  diseases  of  the  lungs  in  American  industry.  Penn- 
sylvania Medical  Journal,  Athens,  1916,  xx,  33-48. 

Cunningham,  W.  P.  Health  insurance.  New  York  Medical  Journal,  1917,  cvi, 
683-686. 


BIBLIOGRAPHY  805 

CtTRRAN,  J.  F.  Relation  of  industrial  surgeon  to  industry  and  to  society.  Boston 
Medical  and  Surgical  Journal,  1918,  clxxviii,  215-217. 

Curtis,  W.  G.  Economic  disadvantages  of  compulsory  health  insurance  (and 
comments).  New  York  State  Journal  of  Medicine,  New  York,  1917,  xvii, 
75-81. 

Cutler,  R.  W.  Physical  examination  of  factory  employees;  two  thousand  con- 
secutive cases  and  the  defects  found.  Boston  Medical  and  Surgical  Journal, 
1917,    clxxvii,    627-631. 

Dangers  of  the  airplane  industry  from  a  hygienic  standpoint.  Monthly  Review  of 
the  W.  S.  Bureau  of  Labor  Statistics,  Washington,  1917,  v,  284. 

Darlington,  Thomas.  Address  on  prolonging  the  lives  of  busy  men.  New  York, 
1918. 

.     Physiological    principles    applied    to   industry.     International    Clinics, 

Philadelphia,  1916,  26,  s.,  iv,  142-146. 

Present  scope  of  welfare  work  in  the  iron  and  steel  industry.     Modern 


Hospital,  St.  Louis,  1916,  vii,  91-94. 
Davin,  J.  P.     Compulsory  health  insurance.     American  Medicine,   New  York, 

1917,  xii,  188-193. 
Dawson,  M.  M.     Contribution  of  health  insurance  to  improvement  of  public 

health.     Public  Health  Journal,  Toronto,  1917,  viii,  313-317. 
.     What  will  health  insurance  do  for  the  insured?     American  Journal  of 

Nursing,   Philadelphia,   1917,  xvii,   937-942. 
Delphey,  E.  V.     Arguments  against  standard  bill  for  health  insurance.     Journal 

of  the  American  Medical  Association,  Chicago,  1917,  Ixviii,  1500-1501. 
.     Compulsory  health  insurance  from  points  of  view  of  general  practitioner. 

New  York  State  Medical  Journal,  New  York,  1916,  xvi,  601-604. 
Devoto,  L.     I  problem!  igienici  davanti  al  nuovo  industrialismo  italiano.     Pen- 

siero  Medico,  Milano,  1917,  vii,  181-184. 
DiCKERMAN,  C.      Cigarmakers'  neurosis.     National  Eclectec  Medical  Association 

Quarterly,  Cincinnati,   1918-19,  x,  58-66. 
Disabled  (the)  in  industry.     Hospital,  London,  1918,  Ixiv,  511. 
Disabled  men  in  productive  work.     Educational  motion  picture  entitled:  "An 

object  lesson  in  the  employment  of  war  and  industrial  cripples."     Produced 

by  the  Ford  Motor  Co.,  American  Industries,  New  York,  1918,  xix.  No.  1, 

p.  24-25. 
DoANE,    P.   S.     Health  and  sanitation  in  the  shipyards.     New  York   Medical 

Journal,    1918,-  cviii,    880. 
Dobbins,  R.  B.     Putting  the  industrially  disabled  back  at  work.     100  per  cent. 

Efficiency' Magazine,  Chicago,  1918,  xi.  No.  3,  p.  76-84;  No.  4,  p.  68,  70-90. 
DoDsoN,  J.  M.     Preventive  medicine  in  railway  work.     Journal  of  the  Minnesota 

State  Medical  Association  and  the  Northwestern  Lancet,  Minneapolis,  1918, 

xxxviii,    91-97. 

.     Medical  Insurance  and  Health  Conservation,  Dallas,  1918,  xxvii,  219-222. 

DoNNET,  E.  H.     Making  of  rates  for  workmen's  compensation  insurance.     Journal 

of  Political  Economy,  Chicago,  1917,  xxv,  961-983. 
DoNOGHUE,    Frances    D.     The   history   and    operation    of   the    Massachusetts 

workingman's    compensation  law.     Boston   Medical  and   Surgical  Journal, 

1916,  clxxv,  897-902. 
.     The  rehabilitation  of  crippled  workmen.     In:  Massachusetts  Industrial 

Accident  Board.     Annual  report  No.  3,  Boston,  1916,  p.  82-101. 
— .     Restoring  the  injured  employee  to  work.     Boston  Medical  and  Surgical 

Journal,   1916,   clxxv,   457-461. 


806  INDUSTRIAL    MEDICINE    AND    SURGERY 

Doty,  A.  H.     The  value  of  examination  of  applicants  for  industrial  employment. 

Medical  Record,  New  York,  1916,  Ixxxix,  952-954. 
Double  Duty  Finger  Guild.     Steady,  remunerative  work  for  the  blind.     Ampere, 

N.  J.,    1918. 
Douglas,  Paul  H.     An  after-care  clinic  in  Oregon.     American  Lavor  Legislation 

Review,  New  York,  1919,  ix,  134-136. 
Dublin,  L.  I.     Occupational  mortality  experience  of  94,269  industrial  workers. 

American  Journal  of  Public  Health,  New  York,  1916,  663-670. 
Dublin,  L.  J.  and  Jacobs,  P.  P.     Tuberculosis  as  a  war  problem.     Journal  Out- 
door Life,  vol.  xiv.  No.  12. 
DucLOT.    Quelques  considerations  sur  le  travail  des  f emmes  dans  les  establessement, 

de  la  marine.     Archives  de  Medecine  et  Pharmacie  Navales,  Paris,  1917,  civ, 

5-11. 
Duncan,  Jambs  P.     The  aims  of  industrial  welfare.     Modern  Hospital.     St.  Louis, 

1916,  vii,    127-128. 

Eaton,  J.  M.     Industrial  welfare  work  a  factor  in  modern  management.     Modern 

Hospital,  St.  Louis,  1916,  vii,  104-109. 
Edsall,  D.  L.     The  bearings  of  industry  on  medical  practice.     Boston  Medical 

and  Surgical  Journal,  1917,  clxxvii,  575. 
.     Medical-industrial    relations    of    the    war.     Johns    Hopkins    Hospital 

Bulletin,  Baltimore,  1918,  xxix,  197-205. 

The  prevention  of  disease  in  war  industries.     Extent  and  importance 


of  the  problem.     Medical  Record,  New  York,  1918,  xciii,  611. 
.     Supposed   physical   effects   of  the  pneumatic   hammer  on   workers   in 

Indiana  limestone.     Public  Health  Reports,  Washington,  1918,  xxxiii,  394- 

403. 
Edwars,  J.  W.     Industrial  diseases  prevailing  amongst  iron  and  steel  workers  in 

Middlesbrough.     British  Medical  Journal,  1916,  ii,  97-99. 
EisENBERG,  A.  A.     Visceral  changes  in  wood  alcohol  poisoning  by  inhalation. 

American  Journal  of  Public  Health,  New  York,  1917,  vii,  765-771. 
EisENSTADT,  H.  L.     Bcitrage  zu  den  Krankheiten  der  Postbeamten.     Berlin,  1916. 
Emmons,  A.  B.     Industrial  Medical  supervision.     Boston  Medical  and  Surgical 

Journal,  1916,  clxxiv,  495-499. 
Employment   results   in    Philadelphia,   American  Journal  of  Care   for   Cripples. 

New  York,   1916,  iii,  42-44. 
Employment  of  crippled  in  a  large  industrial  plant.     Monthly  Labor   Review, 

Washington,  1918,  vii,  no.  6,  p.  85-86. 
Erdman,  S.     Standards  for  the  prevention  of  compressed  air  illness.     American 

Journal  of  Public  Health,  Concord,  1918,  viii,  431-434. 
EsTES,  W.  L.     Compensation  laws  of  the  potent  factors  in  the  prevention  and 

treatment  of  occupational  diseases  and  industrial  accidents.     Transactions 

of  the  College  of  Physicians,  Philadelphia,  1917,  3  s,  xxxix,  439-455. 
Evans,  William  A.     Industrial  physicians  and  the  returning  soldier.      Survey, 

New  York,   1918,  xl,  354. 
Eve,  D.     a  discussion  of  seven  thousand  industrial  injuries.     Journal  of  the  Ten- 
nessee State  Medical  Association,  Nashville,  1918-19,  xi,  269-276. 
.     The  necessity  of  making  blood  pressure  examinations  of  engineers  over 

60,  at  stated  intervals.     Railway  Surgical  Journal,  Chicago,  1917-18,  xxiv, 

265-270. 
.     Experiment   (an)   in  fair  dealing   Modern  Hospital,  Chicago,  1919,  xii, 

144-146. 


BIBLIOGRAPHY  807 

Farnam,  Henry  W.     The  Seaman's  act  of  1915.     9th  annual  meeting — American 

Assn.  for  Labor  Legislation — Dec.  28,   1915. 
Farnum,  G.  G.     Modern  industrial  medicine.     Journal  of  the  American  Medical 

Association,  Chicago,  1918,  Ixxi,  336-338. 
.     The  relationship  of  impaired  physical  condition  to  accidents.     American 

Journal  of  Public  Health,  New  York,  1916,  vi,  470-473. 
The  Ideal   Industry   from  the  Standpoint  of  Health  and  Safety — Nail  Safety 

Council,  Chicago,  1917. 
Fay,  a.  H.     Metal-mine  accidents  in  the  United  States  during  the  calendar  year 

1915.     American  Journal  of  Public  Health,  Concord,  1916,  vi,  1235. 
Feiss,  R.  a.     Scientific  management  and  its  relation  to  health  of  worker.      Ameri- 
can Journal  of  Public  Health,  New  York,  1917,  vii,  262-267. 
Ferretti,  U.     Ill  Convegno  degli  industriali  del  freddo,  nei  riguardi  igiemici. 

Annali  d'Igiene,  Roma,  1917,  xxvii,  38-41. 
First-aid  equipment  for  industrial  plant.     Modern  Hospital,  St.  Louis,  1918,  x, 

305-306. 
Fisher,  I.     Need  for  health  insurance.     New  York  State  Journal  of  Medicine 

New  York,  1917,  xvii,  81-84. 
Fisher,   Hart  E.     Now  adhering  surgical  gauze — used  in  Emergency  Surgery. 

Jour.  A.  M.  A.,  vol.  Ixvi,  pp.  929.     First  aid  system — (Interstate  Med.  Journal, 

vol.  xxii,  No.  10,  1916. 
FisKE,  C.  N.     Suggested  use  of  combined  table  of  occupational  distribution  of 

physical  disability.     U.  S.  Naval  Medical  Bulletin,  Washington,  1916,  x,  199- 

213. 
Fleischer,   Alexander.     Welfare  service  for  employees.     Philadelphia,    1917. 

Reprinted  from  Annals  of  the  American  Academy  of  Political  and  Social 

Sciences,  January,  1917. 
Florence,  P.  S.     Methods  for  field  study  of  industrial  fatigue.     Public  Health 

Reports,  Washington,  1918,  xxxiii,  349-353. 
Floret.     Erfahrungen  mit  verschiedenen  Handereinigungsmitteln  bei  Arbeitern 

in  der  Chemischen  Industrie.     Zentralblatt  fiir  Gewerbehygiene,  Berlin,  1915, 

iii,    238-240. 
Foley,  Edna  L.     Visiting  nurse  in  industry.     Modern  Hospital,  St.  Louis,  1916, 

vii,  125-127. 
Ford,  James  S.     Employment  of  persons  in  the  arrested  stage  of  tuberculosis. 

Medical  Record,  New  York,  1916,  xc,  1154-1155. 
Forrester,   C.  R.   G.     The  prevention  of  disability  following  fracture  of  the 

OS  calcis.     Illinois  Medical  Journal,  Chicago,  1916,  xxx,  385-388. 
Frankel,  Lee  K.     Systematic  health  service  for  employees.     Modern  Hospital, 

St.  Louis,      1916,  vii,  87-90. 
.     Welfare  work  of  the   Metropolitan  Life   Insurance   Company  for  its 

employees.     New  York  State.     Journal  of  Medicine,  New  York,  1917,  xvii, 

38-40. 
Freeman,  J.  W.     Fractures  of  the  different  bones  occurring  in  the  gold  mining 

industry;  end-results  and  economic  study  of  311  consecutive  cases.     Annales 

of  Surgery,  Philadelphia,  1917,  Ixvi,  193-200. 
Freiberg,  A.  H.     The  casualties  of  War  and   Industry   and   their  relation  to 

Orthopedic  Surgery.     Jour.  A.  M.  A.,  vol.  Ixxi,  No.  6,  p.  417. 
French,    W.    J.     Accident   prevention   in    California.     In:  Proceedings   of   the 

Conference  of  Social  Insurance,  1916,  Washington,  1917,  p.  267-272,  283-291. 
.     Cooperative  methods  to  promote  industrial  safety.     Proceedings  of  the 

International  Association  of  Industrial  Accident  Boards,  1916,  Washington, 

1917,  iii,  145-151. 


808  INDUSTRIAL    MEDICINE    AND    SURGERY 

Fronczak,   F.   E.     Modern  chemical  industries  and  public  health.     American 

Journal  of  Public  Health,  New  York,  1917,  vii,  268-272. 
FuLLERTON,  HuGH.     Make  men  as  well  as  goods.     Modern  Hospital,  St.  Louis, 

1916,  vii,  346-347. 

Gana,  V.  Q.  La  industria  de  curtidos  en  las  Islas  Filipinas.  Actas,  Memorias  y 
comunicaciones  de  la  3.  Assemble  a  regional  dm6e  dicos  y  farmaceuticos  de 
Fihpinas  Manita,  1917,  498-521. 

Geier,  O.  p.     Health  of  working  forces.     Industrial  Management,  New  York, 

1917,  liv,  13-19.     The  human  potential  in  Industry.     Jour.  American  Soc. 
Mechanical  Engineers,  N.  Y.,  1917. 

Gentry,  J.  A.  Medical  supervision  of  employees  in  large  industries.  Southern 
Medical  Journal,  Birmingham,  1918,  xi,  115-119. 

Gesundheitlichen  (die)  Verh  altnisse  in  den  vergoldereien.  Zentralblatt  fiir 
Gewerbehygiene,  Berlin,  1915,  iii,  280-284. 

Gesundheitsverhaltnisse  der  Arbeiter  in  englischen  Munitionsfabriken.  Deutsche 
medizinische  Wochenschrift,  Leipzig,  1917,  xliii,  1269. 

Gewin,  W.  C.  The  relation  of  the  surgeon  to  industrial  corporation.  Interna- 
tional Journal  of  Surgery,  Nev/  York,  1917,  xxx,  109-111. 

Gibbons.  Work,  principles  and  problems  of  industrial  accidents.  California 
State  Journal  of  Medicine,  San  Francisco,  1916,  xiv,  470. 

Gilberti,  p.  Ernia  da  infortunio.  Pensiero  Medico,  Milano,  1915,  v,  523,  537, 
562. 

GiLBRETH,  Frank  B.  and  Lillian  M.  Gilbreth.  Creating  the  cripple's  oppor- 
tunity.    Iron  Trade  Review,  Cleveland,  1918,  Ixii,  268-269. 

.     Fatigue  study,  the  elimination  of  humanity's  greatest  unnecessary  waste ; 

a  first  step  in  motion  study.     New  York,  1916. 

Measurement  of  the  human  factor  in  industry.     (To  be  presented  at  the 


National  Conference  of  the  Western  Efficiency  Society,  May  22-25,  1917). 

N.p.,    n.d. 
Gilson,    M.   B.     Recreation  of  working  force.     Industrial   Management,    New 

York,    1917,  liv,   13-19. 
GoLDMARK  Josephine.     Women  workers  in  new  occupations.     Manufacturers' 

News,  Aug.  8,  1918. 
GoLDWATER,  S.  S.     The  conservation  of  the  health  of  industrial  workers.     Modern 

Hospital,  St.  Louis,  1917,  vii,  124-125. 
Great  Britain,  Ministry  of  Munitions.     Health  of  Munition  Workers  Committee. 

Health  of  the  munition  workers.     London,  1917. 
GuTON,    L.     Conditions    d 'insalubrity  des   etablissements  industriels.     Bulletin 

Sanitaire,  Montreal,  1916,  xvi,  86-92. 

Haldane,  J.  S.     Dust  inhalation  and  the  health  of  miners.     Medical  Officer, 

London,  1918,  xx,  146. 
Haldt,  W.  a.     Welfare  work  in  the  modern  factory.     Cleveland  Medical  Journal, 

1915,   xiv,    757-761. 
Hall,  H.  J.  and  M.  M.  C.  Buck.     Handicrafts  for  the  handicapped.     New  York, 

1916. 
Hambrecht,    George    P.     Industrial   experience    of   handicapped    workmen   in 

Wisconsin.     American    Labor    Legislation    Review,    New    York,    1919,   ix, 

117-125. 
Hamilton,  Alice.     Dangers  other  than  accidents  in  the  manufacture  of  explo- 
sives.    Journal  of  Industrial  and  Engineering  Chemistry,  Easton,  1916,  viii, 

1064-1067. 


BIBLIOGRAPHY  809 

Hamilton,  Alice.  The  fight  against  industrial  diseases;  the  opportunities  and 
duties  of  the  industrial  physician.  Pennsylvania  Medical  Journal,  Athens, 
1918,  xxi,  378-381. 

.     Industrial  poisons  encountered  in  manufacture  of  explosives.     Journal  of 

the  American  Medical  Association,  Chicago,  1917,  Ixviii,  144.5-1451. 

Prophylaxis  of  industrial  poisoning  in  the  munition  industries.     American 


Journal  of  Public  Health,  Concord,  1918,  125-130. 
Hamilton,  Alice  and  Charles  H.  Verrill.     Hygiene  of  the  printing  trades. 

Washington,  1917. 
Harford,  C.  F.     Visual  neuroses  of  miners.     British  Medical  Journal,  London, 

1916,  i,  434. 
Harrington,  T.  F.     Health  in  war  industries.     Boston  Medical  and  Surgical 

Journal,   1918,  clxxviii,    453-458. 
.     Industrial  health.     American  Journal  of  Public  Health,  New  York,  1917, 

vii,  322-330. 

Occupational  diseases  in  Massachusetts.     Boston  Medical  and  Surgical 


Journal,  1917,  clxxvii,  153. 
Harris,  Louis  I.     A  clinical  study  of  the  frequency  of  lead,  turpentine  and  benzin 

poisoning  in  400  painters.     Archives  of  Internal  Medicine,  Chicago,  1918, 

xxii,  129-156. 
.     A  clinical  and  sanitary  study  of  the  fur  and  hatters'  fur  trade.     New 

York,  1915.     (Dept.  of  Health,  City  New  York,  Monograph  series  No.  12.) 
.     Labor  sanitation  conference.     New  York  City  Department  of  Health 

Bulletin,  1917,  vii,  61-66. 
.     Municipality  in  industrial  hygiene.     Scientific  American  Supplement, 

New  York,  1917,  Ixxxiii,  2-3. 

The  opportunities  which  industrial  hygiene  offers  to  the  general  practi- 


tioner and  to  the  public  health  officer.     New  York,  1917.      (Department  of 

Health,  City  of  New  York,  Reprint  series  No.  62.) 
Harvey,  A.  M.     Oblique  inguinal  hernia.     Tel.  Med.  Journal,  vol.  xxxiii,  No.  3, 

p.  154. 
Hatfield,  C.  J.     Tuberculosis  as  it  affects  the  worker.     Monthly  Bulletin  of  the 

Pennsylvania  Department  of  Labor,  Harrisburg,  1917,  iv,  99-106. 
Haultain,  H.  E.  T.     Industrial  rehabilitation.     Canadian  Medical  Association 

Journal,  Toronto,  1918,  viii,  703-705. 
Haxjtey,    Horton    Smith   P.     Tuberculosis   in   its   relation   to   the   war — after 

employment  of  the  tuberculous.     Recalled  to  life.     London,  Sept.,  1917. 
Hawes,  J.  B.,  Jr.     Tuberculosis;  an  industrial  accident.     Medicine  and  Surgery, 

St.  Louis,   1917,  i,  777-779. 
Hayhtjrst,    E.    R.     The    classification    of    hazardous    occupations.     American 

Journal  of  Public  Health,  New  York,  1916,  vi,  460-469. 
.     Compulsory  state-wide  health  insurance  and  its  relation  to  the  medical 

service.     Modern  Hospital,  St.  Louis,  1916,  vi,  420-424. 
.     Industrial   hygiene.     Ohio    Public    Health   Journal,    Columbus,    1916, 

vii,  153. 
.     The  need  for  a  general  system  of  sanitary  supervision  of    industries 

in  times  of  war.     American  Journal  of  Public  Health,  Concord,  1918,  viii, 

301-303. 
.     Occupational  diseases.     Ohio  Public  Health  Journal,  Columbus,  1917, 

viii,  33-38. 
.     Relation  of  industrial  diseases  and  accidents  to  medicine.     Ohio  State 

Medical  Journal,  Columbus,  1916,  xii,  20. 
.     A    survey    of    industrial    health-hazards    and  occupational  diseases  in 


810  INDUSTRIAL   MEDICINE    AND    SURGERY 

Ohio.     Ohio  PubUc  Health  Journal,   Columbus,   1915-16,  vi,  44,  289,   419, 

514,  655. 
Health  insurance.     Michigan  State  Board  of    Health  Bulletin,  Lansing,    1917, 

V,  423-430. 
Health    insurance    officially    endorsed.     American    Labor    Legitsiation    Review, 

New  York,   1917,  vii,  201-225. 
Health  of  munition  workers  in  relation  to  their  working  output.     Journal  of  the 

American  Medical  Association,  Chicago,  1917,  Ixviii,  203-204. 
Health  of  munition  workers.     British  Medical  Journal,  London,  1917,  I,  847;  II,  49. 
Health  (the)  of  munition  workers.     Lancet,  London,  1917,  I,  692. 
Health  (the)  of  munition  workers.     Lancet,  London,  1916,  I,  785. 
Health  and  sanitation  work  in  the  shipyards.     New  York  Medical  Journal,  1918, 

eviii,  598. 
Health  and  welfare  of  munition  workers  outside  the  factory.     Monthly  Review  of 

the  U.  S.  Bureau  of  Labor  Statistics,  Washington,  1917,  v,  291. 
Henderschott,  F.  C.  and  Weakly,  F.  E.     The  employment  department  and 

employee's  relations.     LaSalle  Extension  University,  Chicago,  1918. 
Henry,  B.  F.     Some  observations  on  dust  separator  problems.     Metal  Worker, 

Plumber  and  Steam-fitter,  New  York,  1917,  Ixxxvii,  479-481. 
Hewes,  Amy  and  Henriette  R.  Walter.     Women  as  munition  makers.     New 

York,  1917. 
Highley,  G.  O.     The  safe  limit  of  carbon  dioxide  in  the  working  atmosphere. 

American  Journal  of  Public  Health,  Concord,  1918,  viii,  477-481. 
Hochhauser,  Edward.     Home  treatment  for  the  tuberculous.     Modern  Hospital, 

St.  Louis,  1917,  viii,  207-208. 
Hoffman,   Frederick  Ludwig.     Mortality  from  respiratory  diseases  in  dusty 

trades.     Washington,  1918.     (Bulletin  of  the  U.  S.  Bureau  of  Labor  Statistics, 

No.  231.) 
.     Omission  of  occupational  diseases  as  a  defect  in  workmen's  compensation 

laws.     In:  Proceedings  of  the  Conference  of  Social  Insurance,  1916,  Washing- 
ton, 1917,  p.  377-417. 
.     Some  fallacies   of   compulsory   health   insurance.     Scientific    Monthly, 

Garrison,  N.  Y.,  1917,  iv,  306-315. 

Some  theoretical  and  practical  aspects  of  industrial  medicine.     Transac- 


tions of  the  College  of  Physicians,  Philadelphia,  1917,  3  s.,  xxxix,  421-438. 

Holden,  O.  The  effects  of  electric  arc  welding  upon  the  eyes  and  skin.  British 
Medical  Journal,  London,  1918,  I,  454. 

HoLMAN,  Dudley  M.  Educational  work  in  accident  prevention.  Proceedings 
of  the  International  Association  of  Industrial  Accident  Boards,  1916,  Washing- 
ton,  1917,  iii,   128-144;  151-157. 

.     The  problem  of  the  handicapped  man.     Bulletin  of  the  United  States 

Bureau  of  Labor  Statistics,  No.  212,  Washington,  1917,  p.  348-357. 

HooKSTADT,  Carl.  Comparison  of  experience  under'  workmen's  compensation 
and  employers'  liability  systems.  Monthly  Labor  Review,  Washington,  1919, 
viii,  No.  3,  p.  230-248. 

.     Probability  of  an  industrial  cripple  sustaining  a  second  injury.     Monthly 

Labor  Review,  Washington,  1919,  viii,  No.  3,  p.  79-84. 

.     Problem   of  the  handicapped  man  in  industry.     Monthly  Review  of 

the  U.  S.  Bureau  of  Labor  Statistics,  Washington,  1918,  vi,  No.  3,  p.  87-92. 

.  Shall  the  ambitious  cripple  suffer  loss  of  workmen's  compensation  bene- 
fits?    American  Labor  Legislation  Review,  New  York,  1919,  ix,  137-140. 

.     What  becomes  of  men  crippled  in  industry?     Monthly  Labor  Review, 


Washington,  1918,  vii,  No.  1,  p.  32-49. 


BIBLIOGRAPHY  811 

Hopkins,  C.  W.  Industrial  welfare  work  as  applied  to  railroads.  Railway 
Surgical  Journal,  Chicago,   1917-1918,  xxiv,  29-36. 

.     Traumatic  hernia,   so-called  among  railway  employees.     International 

Journal  of  Surgery,  New  York,  1916,  xxix,  24-28. 

Hospital  work  and  x-ray  research.  Eastman  kodak  company,  Rochester,  N.  Y. 
Modern  Hospital,  St.  Louis,  1917,  viii,  29.5-296. 

Hours,  fatigue  and  health  in  British  munition  factories.  Washington,  1917. 
(U.  S.  Bureau  of  Labor  Statistics.     Bulletin  No.  221.) 

Hours  of  labor;  industrial  fatigue  and  output  in  England.  Scientific  American 
Supplement,  New  York,  1917,  Ixxix,  290. 

How  industrial  fatigue  may  be  reduced.  Public  Health  Reports,  Washington, 
1918,   xxxiii,    1347-1355. 

Howell,  Thomas.  Hospitals  and  workmen's  compensation.  Operation  of  com- 
pensation laws  to  decrease  industrial  accidents  and  to  improve  traumatic 
surgery.     Modern  Hospital,  St.  Louis,  1917,  ix,  234-239. 

HowK,  H.  J.  AND  D.  Everett  Waid.  Metropolitan  life  insurance  company 
tuberculosis  sanatorium.     Modern  Hospital,  St.  Louis,  1916,  278-287. 

Hudson,  W.  G.  Medical  supervision  of  tri^nitrotolnol  workers.  New  York 
Medical  Journal,  1918,  cvii,  723. 

.    Safeguards  in  the  manufacture  of  explosives.     New  York  Medical  Journal, 

1918,  cvii,    248-250. 

Industrial  accidents.     Journal  of  the  American   Medical  Association,   Chicago, 

1916,  Ixvii,     1307-1308. 

Industrial  accidents  among  bridge  and  structural-iron  workers,  Chicago.     Monthly 

Labor  Review,  Washington,  1919,  viii,  No.  3,  pp.  225-226. 
Industrial  accidents  in  Massachusetts  in  1916-1917.     Monthly  Labor  Review, 

Washington,  1919,  viii,  No.  3,  pp.  223-225. 
Industrial  cripples  and  rehabilitation.     Survey,  New  York,  1918,  xl,  162. 
Industrial  fatigue;  investigation  by  means  of  factory  statistics.     Public  Health 

Reports,  Washington,  1918,  xxxiii,  1733. 
Industrial  surgeons  ask  U.  S.  for  recognition.     Association  says  care  of  workers 

is   necessary  war   measure.     Reconstruction   machinery   to   help   industrial 

cripples.     Hospital  Management,  Chicago,  1918,  v,  No.  5,  pp.  32,  34,  36,  38. 
Injurious  dusts  in  steel  works.     Monthly  Review  of  the  U.  S.  Bureau  of  Labor 

Statistics,  Washington,  1917,  v,  285. 
Insurance,    old    age,    unemployment,    sickness,    etc.     Journal    of   the    American 

Medical  Association,  Chicago,  1917,  Ixviii,  1730-1755. 
Is  hernia  a  compensable  injury  or  a  disease?     Monthly  Labor  Review,  Washington, 

1919,  viii,  3,  p.  249-250. 

Jackson,  J.  P.  The  attitude  of  the  Dept.  of  Labor  and  Industry  toward  the 
problem   of  occupational  diseases.     Pennsylvania  Medical  Journal,  Athens, 

1917,  XX,   472-478. 

Jarrett,  Mary  C.  The  psychopathic  employee:  a  problem  of  industry.  Medi- 
cine and  Surgery,  St.  Louis,  1917,  i,  727-741. 

Jenkins,  Frederick  Warren  and  Bertha  Fairfield.  Employment  for  the 
handicapped,  a  selected  bibliography.  New  York,  1917. 

Jones,  Ruth  Montgomery.  A  placement  bureau  for  the  handicapped.  Modern 
Hospital,  St.  Louis,  1918,  x,   165-169. 

Jones,  N.  M.  Some  medical  and  surgical  problems  and  their  solution  from  the 
viewpoint  of  the  public  service  corporation  surgeon.  Pennsylvania  Medical 
Journal,   Athens,    1918,  xxi,   352-355. 


812  INDUSTRIAL    MEDICINE    AND    SURGERY 

Kahn,  M.  H.     Report  of  the  committee  on  industrial  hygiene  of  the  retail  dry  goods 

association.     Medical  Record,  New  York,  1916,  xc,  943-945. 
Kane,  E.  O'H.     Women  in  railway  service  as  viewed  from  a  surgical  standpoint, 

pertinent   to   the   present   world   war.     International   Journal   of   Surgery, 

New  York,  1917,  xxx,  362-364. 
Kaylor,  R.  J.     Youngstown  Sheet  and    Tube  Company's    Hospital.     Modern 

Hospital,  St.  Louis,  1916,  vii,  109-110. 
Kelly,   D.   F.     The  department  store  hospital.     Modern  Hospital,  St.  Louis, 

1916,  vii,   345-346. 

Kent,  A.  F.  Stanley.     Fatigue  induced  by  labor.     Bristol  Medico-Chirurgical 

Journal,    1917,    xxxv,    47-60. 
.     Second  interim  report  on  an  investigation  of  industrial  fatigue  by  physio- 
logical methods,  London,   1916. 
Kerr,  J.  W.     Relation  of  public  health  service  to  problems  of  industrial  hygiene. 

American  Journal  of  Public  Health,  Concord,  1917,  vii,  776-782. 
Kerr,  J.  W.,  S.  M.  McCurdy  and  O.  P.  Geier.     The  scope  of  industrial  hygiene. 

Journal  of  the  American  Medical  Association,  Chicago,  1916,  Ixvii,  1821-1862. 
Kingston,  G.  A.     A  comparison  of  the  treatment  of  permanent  partial  disability 

cases.     Proceedings  of  the  International  Association  of  Industrial  Accident 

Boards,  1916,  Washington,   1917,  iii,  159-163. 
KiRKWooD,  Frances.     Following  a  vision  of  better  men  and  women.     Modern 

Hospital,  St.  Louis,  1917,  ix,  221-222. 
Knoeppel,  C.  E.     Women  in  Industry,  Society  of  Industrial  Engineers  &  Western 

Efficiency    Society,    Chicago,    1918. 
KoBiCK,  Henry  G.     "Health  First"  is  the  motto.     Modern  Hospital,  St.  Louis, 

1917,  viii,  231-232. 

KoELSCH.     Gewerbehygienische  Uebersicht.     Miinchener  medicinische  Wochen- 

schrift,  1918,  xxxiii,  1347-1355. 
KoELSCH,  F.  and  a.  Arnstein,     Ueber  die  Lungenerkrankungen  der  Steinhauer. 

Zentralblatt  fiir  Gewerbehygiene,  Berlin,  1915,  iii,  259-264,  273-279. 
KoRTEWEG,  J.  A.     Het  ongevallen-percentage  en  de  fabrieksdokter.     Nederal- 

andsch  Tyjdschrift  von  Geneeskunde,  Amsterdam,  1917,  Ix,  597-614. 
Krantz.     Explosion  einer  Anlage  zur  Herstellung  von  Wasserstoff.     Zentralblatt 

fiir  Gerwerbehygiene,  Berlin,  1915,  iii,  253-259. 

Lambert,  Alexander.     Medical  organization  under  health  insurance.     American 

Association  Labor  Legislation,  Columbus,  1916. 
Landis,  H.  R.  M.     Health  efficiency  of  workers  due  to  their  living  conditions. 

International  Clinics,  Philadelphia,  1917,  27  s.,  i,  138-144. 
Lapp,  John  A.     Health  insurance  and  the  hospital.     American  Hospital  Associa- 
tion,  Atlanta,   Sept.    27,   1918. 
Landry,  L.   H.     Intracranial  hemorrhage  due  to  traumatic  rupture  of  arteria 

meningea  media,  report  of  six  operated  cases  with  one   death.      Southern 

Medical  Journal,  Nashville,  1916,  ix,  157-166. 
Lanza,  A.  J.     Hazards  of  metal  mining.     Medical  Record,  New  York,  1918,  xciv, 

394. 
.     Miner's  consumption:  a  study  of  433  cases  of  the  disease  among  zinc 

miners  in  southwestern  Missouri.     Wisconsin  Medical  Journal,  Milwaukee, 

1917,  xvi,  64-66. 
Lauffer,  Chas.  a.     Inguinal  hernia  viewed  as  an  anatomical  defect.     Second 

Conference  Industrial  Surgeons,  Harrisburg,  May  18,  1916. 
Leake,  J.  P.     Health  hazards  from  the  use  of  the  air  hammer  in  cutting  Indiana 

limestone.     Public  Health  Reports,  Washington,  1918,  xxxiii,  379-393. 


BIBLIOGRAPHY  813 

Leclercq,  J.,  Mazel,  and  R.  Dujarric  de  la  Rivi£;re.  R61e  du  m(5dicin  dans 
I'industrie  apres  la  guerre;  orientation  et  utilisation  physiologiques  de  I'ouv- 
rier.     Annales  de  Hygiene  et  de  M6dicin  Legale,  Paris,  1917,  xxvii,  345-390. 

Lee,  Frederic  Schiller.  The  human  machine  in  industry.  Columbia  Alumni 
News,  New  York,  1918,  ix.  No.  14,  pp.  1-10. 

.     Industrial  efficiency;  the  bearing  of  physiological  science  thereon;  a 

review  of  recent  work.     Public  Health  Reports,  Washington,  1918,  xxxiii, 
29-35. 

.     Industrial   service  in  tire  factory.     Modern  Hospital,  St.  Louis,   1917, 

viii,  353. 

Periodic  examination  of  employees.     Modern  Hospital,  St.  Louis,  1916, 


vii,    350. 
Lemon,  C.  H.     Medical  supervision  of  street  railway  employees.     Journal  of  the 

American  Medical  Association,  Chicago,  1917,  Ixviii,  95-98. 
.     Social  medicine  in  the  industries.     Wisconsin   Medical  Journal,    Mil- 
waukee, 1917-1918,  xvi,  453-459. 
Lesieur,  C.     Hygiene  des  travailleurs.     Du  role  des  adjoints  techniques  dans  la 

surveillance  hygienique  et  epidemiologique  des  travailleurs  francais  indigenes 

et   etrangers  employes  dans  les  ^stablissements  travaillant  pour  la  guerre. 

Archives  de  Medecine  et  de  Pharmacie  Militaires,  Paris,  1917,  Ixvii,  76-96. 
Levings,  a.  H.     Traumatic  hernia  and  traumatic  orchites  in  relation  to  workmen's 

compensation.     Wisconsin  Medical  Journal,  Milwaukee,  1915,  xiv,  273-276. 
Levy,  E.     Workers  in  compressed  air;  precautions  adopted  by  the  N.  Y.  Public 

Service  Commission  for  protecting  their  health.     Scientific  American  Supple- 
ment, New  York,  1917,  Ixxxiv,  73. 
Light,  A.  B.     Thresher's  fever.     Therapeutic  Gazette,  Detroit,  1918,  xxxiv,  615- 

619. 
Little,  R.   M.     Who  shall  bear  the  extraordinary  compensation  cost  of  total 

disability  caused  by  successive  injuries  ?     American  Labor  Legislation  Review, 

New  York,   1919,  ix,   141-149. 
Lord,  C.  B.     Athletics  for  working  force.     Industrial  Management,  New  York, 

1917,  liv,  44-49. 
LovEJOY,   F.   W.     Big  benefit  fund  basis  of  welfare  work.     Modern  Hospital, 

St.  Louis,  1916,   vii,   349. 
Lowman,  J.  B.     Value  of  physical  examination  as  a  factor  in  the  prevention  of 

industrial  injury.     Pennsylvania  Medical  Journal,  Athens,  1916,  xx,  48-55. 
Lynott,  W.  A.     Bureau  of  mines'  studies  of  occupational  diseases.     Journal  of 

Industrial  and  Engineering  Chemistry,  Easton,  1916,  viii,  1062-1064. 
Lyons,  Barrow  B.     Northeastern  hospital  of  Philadelphia  to  serve  corporations  on 

a  co-operative  basis.     Modern  Hospital,  St.  Louis,  1917,  ix,  306-307. 

McAllister,  J.  B.  How  the  workmen's  compensation  act  may  be  made  satisfac- 
tory to  the  profession.  Pennsylvania  Medical  Journal,  Athens,  1916,  xix, 
736-739. 

McCleery,  Agnes  P'.  The  value  of  employees'  medical  and  social  service  depart- 
ments.    Modern  Hospital,  St.  Louis,   1916,  vii,  208-210. 

MoCoMAS,  R.  T.  Welfare  work  of  Cincinnati  and  Suburban  telephone  company 
includes  country  home  where  girls  go  to  rest.  Modern  Hospital,  St.  Louis, 
^  1917,  viii,  75-77. 

McCiTLLOUGH,  J.  W.  S.  Hours  of  work  in  relation  to  efficiency  and  output  of 
munition  workers.     American  Medicine,  Burlington,  1917,  xxiii,  402. 

McCttrdy,  S.  M.  The  industrial  dispensary  in  preventive  medicine.  Journal  of 
the  American  Medical  Association,  Chicago,  1917,  Ixix,  1318. 


814  INDUSTRIAL    MEDICINE    AND    SURGERY 

McCuRDY,  S.  M.  Physical  examination  and  regeneration  of  employees.  Journa 
of  the  American  Medical  Association,  Chicago,  1915,  Ixv,  2050-2054. 

Macdonald,  J.  S.  Man's  mechanical  efhciency  in  work  performance  and  the  cost 
of  movements  involves  (treated  separately) .  Proceeding  of  the  Royal  Society, 
London,    1917,    Ixxxix,    394-410. 

McKendrick,  Archibald.  Back  injuries  and  their  significance  under  the  work- 
men's compensation  and  other  acts.     Edinburgh,  1916.  • 

McKenna,  H.  Infections  of  the  hand;  their  diagnosis  and  treatment.  Kentucky 
Medical  Journal,  Bowling  Green,  1917,  xv,  290-292. 

Mackey,  Harry  A.  Employment  opportunities  for  rehabilitated  men  in  Pennsyl- 
vania.    American  Labor  Legislation  Review,  New  York,  1919,  ix,  130-133. 

.     Medical  questions  in  the  Pennsylvania  compensation  act,  New  York, 

1916.     Reprinted  from  New  York  Medical  Journal,  April  22  and  29,  1916. 

.     Pennsylvania's  compensation  law  and  the  docter,  Pennsylvania  Medical 

Journal,   1916,  xix,  725-730. 

.     Reclamation  of  the  human  scrap  heap.     1919.     Reprinted  from  North 


American,  January  5,  1919. 
McLeod,  Norman.     What  sick  and  crippled  men  are  doing  for  the  Ford  Motor 

company.     Modern  Hospital,  Chicago,  1919,  xii,  1-3. 
McMuRTRiE,  Douglas  C.     The  rehabilitation  of  the  disabled  civilian.     Testi- 
mony submitted  to  the  Joint  committee  on  education  and  labor  of  the  Senate 

and    House  of    Representatives  in  hearing    on    the    Bankhead-Smith   bill, 

December  10-12,  1918.     New  York,  1918. 
Marks,  L.  B.     Practical  standards  for  factory  illumination.     American  Journal 

of  Public  Health,  Concord,  1918,  viii,  363-367. 
Marriott,    R.    H.     Engineering    precautions    in    radio-installations.     Scientific 

American  Supplement,  New  York,  1917,  Ixxxiii,  266. 
Marsh,  B.  C.     Economic  foundations  for  health.     New  York  State  Journal  of 

Medicine,  New  York,   1917,  xvii,   184-187. 
Marshall,  William  A.     Rehabilitating  the  disabled  victims  of  industry.     Oregon 

Voter,  Portland,  1918,  xiii,  No.  13,  p.  13. 
Massachusetts.     Board  of  Education.     Special  report  of  the  board  of  education 

relative  to  training  for  injured  persons.     Boston,  1917.     (House  Document 

No.  1733.) 
.     House  of  Representatives.     An  act  to  establish  a  division  for  the  training 

of  crippled  and  injured  persons  in  the  department  of  the  industrial  accident 

board.     Boston,  1918.     House  No.  1529. 
.     Legislature.     Resolve  directing  the  board  of  education  to  investigate  the 

subject  of  special  training  for  injured  persons.     Boston,  1916. 
Marquis,   S.   S.     The  factory  doctor.     Transactions  American   Association   of 

Industrial  Physicians  and  Surgeons,  Chicago,  1916. 
Massachusetts  laws  for  training  disabled  soldiers  and  persons  crippled  in  industry. 

Monthly  Labor  Review,  Washington,  1918,  vii.  No.  1,  p.  50-51. 
Massey,  G.  B.     Electrodiagnosis  in  industrial  accidents,  war  wounds,  and  affec- 
tions of  the  motor  apparatus.     Journal  of  the  Medical  Society  of  New  Jersey, 

Orange,    1918,    xv,    146-148. 
Maximum  temperature  in  which  a  workman  can  work.     Heating  and  Ventilating 

Magazine,  New  York,  1917,  xiv.  No.  4,  p.  46-47. 
Mead,  J.  E.     Rehabilitating  cripples  at  Ford  plant.     Iron  Age,  New  York,  1918, 

cii,  739-742. 
Medical  Research  Committee,  London.     A  report  on  the  causes  of  wastage  of 

labor  in  munitions  factories  employing  women,  London,  1918. 


BIBLIOGRAPHY  815 

Medical  examination  of  employees.     Report  of  Committeee  on  Factories,  Chicaf^o 

Tuberculosis  Institute,  1915. 
Mengel,  S.  p.     Some  medical  and  surgical  problems  and  their  solutions :  from  the 

point  of  view  of  the  mining  surgeon.     Proceedings  of  the  Conference  of 

Industrial  Physicians  and  Surgeons,  Athens,  Pa.,  1918,  v,  1-6,  13. 
Mercade.     Large    Eventration   inguine-abdominale    cons6cutive    ilune    plaie    de 

guerre.     Restauration   de  la  parol  par  myoplastie  au  d6pens  du  couturier. 

Bulletins  et  Memoires  de  la  Society  de  Chirurgie  de  Paris,  1916,  xlii,  414. 
Merian,     L.     Ein     Fall    von     Konditorerkrankung.     Corrcspondenz-Blatt     fiir 

schweizer  Aerzte,  Basel,  1916,  xlvi,  305. 
.     Ueber  Haarvwramderung   bei  Munitionsund   Kupferarbeitem.     Corre- 

spondenz-Blatt  fiir  schweizer  Aerzte,  Basel,  1916,  xlvi,  303-305. 
Merrill,  W.  H.     Workingmen's  compensation  for  accident  and  sickness  from  the 

point   of  view   of  the   general   practitioner.     Boston    Medical  and  Surgical 

Journal,    1916,   clxxv,   902-905. 
Miller,  T.  G.     A  sociologic  and  medical  study  of  four  hundred  cigar  workers  in 

Philadelphia.     American  Journal  of    the    American    Sciences,  Philadelphia, 

1918,  civ,  157-175. 
Miller,  T.  G.  and  O.  H.  Pepper.     Experiments  in  the  breathing  of  acid  fumes; 

preliminary  note.     Proceedings  of  the  Pathological  Society  of  Philadelphia, 

1918,  xxxviii,  32. 
Miller,  T.  G.  and  H.  F.  Smith.     The  dust  hazard  in  certain  industries.     Journal 

of  the  -American  Medical  Association,  Chicago,  1918,  Ixx,  599. 
MiLLiGAN,  J.  D.     Methods  and  results  of  first  aid  as  established  by  the  Pittsburgh 

and  Lake  Erie  Railroad  Company.     Pennsylvania  Medical  Journal,  Athens, 

1916,  xix,  689-694. 
MiLTiMORE,  E.     The  relation  of  occupation  to  disease.     Medicine  and  Surgery, 

St.  Louis,  1917,  i,  750-760. 
Mitchell,  D.     Bichromate  works  and  the  effects  on  the  workers.     Journal  of 

State  Medicine,  London,  1916,  xxiv,  18-25. 
Mitchell,    John.     Rehabilitation    legislation    in    the  reconstruction  program. 

American  Labor  Legislation  Review,  New  York,  1919,  ix,  150-151. 

.     Vocational  rehabilitation  of  crippled  industrial  workers.     New  York,  1918. 

Mock,  Harry  E.     Industrial  medicine  and  surgery — the  new  specialty.     Journal 

of  the  American  Medical  Association,  Chicago,  1917,  Ixviii,  1-4. 
.     Night  clinic  on  industrial  medicine  and  surgery  at  Rush  Medical  College. 

Interstate  Medical  Journal,  St.  Louis,  1917,  xxiv,  300. 
.     Present  status   of  medical   examination   of   employees.     In:  National 

Association  for  the  Study  and  Prevention  of  Tuberculosis.     Transactions,  New 

York,    1916,   xii,    219-224. 
.     Human  Maintenance  in  the  industrial  army  during  the  war.     Transactions 

National  Safety  Council,  1917. 
.     Rehabilitation  of  industrial   disabled.     Testimony  given   before  Joint 


committee  on  education  and  labor  of  the  Senate  and  House  of  Representatives 
in  hearing  on  Bankhead-Smith  bill,  Dec.  10-12,  1918,  Congressional  Record. 

IVJoLLAN,  F.  G.  Medical  supervision  of  the  coal  tar  industries.  Buffalo  Medical 
Journal,  1918-19,  Ixxiv,  79-84. 

Moore,  Samuel  H.  Industrial  welfare  work.  Illinois  Gas  Association,  Chicago, 
Mar.   22,    1916. 

MooRHEAD,  John  J.      "Traumatic  Surgery."     Philadelphia,  1917. 

.  Traumatic  Hernia,  Bulletin  American  Association  of  Industrial  Physi- 
cians and  Surgeons,   1917. 


816  INDUSTRIAL    MEDICINE    AND    SURGERY 

Morgan,  J.  L.     Factory  run  by  crippled  men.     Technical  World,  Chicago,  1912, 

xvii,  710-711. 
Mori,  A.     Contributo  alle  affezioni  professional!;  affezioni  dei  portatori  col  big61 

del  Padovano  e  del  Venato.     Ramazzini,  Firenze,  1916,  x,  89-98. 
.     Delle  Asimmetrie  delle  regioni  esterne  del  corpo  umano  in  rapporto  alia 

patolagia  del  lavoro.     Lavoro,  Milan,  1915,  viii,  237-245. 
.     La  Patologia  dei  cavatori  di  alabastromarmai  di  Castellina  Marittima 


Ramazzini,  Firenze,   1916,  x,  99-136. 
Morrison,  M.  L.     Employment  certificates.     New  York  City  Dept.  of  Health 

Bulletin,  1917,  vii,  73-77. 
MoscHcowiTZ,  Alexis  V.     The  relation  of  hernia  to  the  workmen's  compensation 

law.     The  Medical  Record,  Apr.  3,  1915. 
MuLREADY,   E.     The  activities  of  a  labor  department.     Boston    Medical    and 

Surgical  Journal,  1917,  clxxvii,  576-578. 
MuNSON,  E.  L.,  CoL.     "The  Soldier's  Foot  and  the  Military  Shoe."     Collegiate 

Press,  Menasha,  Wis. 

National  Civic  Federation.     The  problem  of  pensions,  Washington,  Jan.,  1916. 
National  Industrial  Conference  Board.     Sickness  insurance  or  sickness  prevention, 

Boston,  1918.     (Research  report  No.  6.) 
.     Workmen's  Compensation  acts  in  the  U.  S. — the  legal  phase,  Boston, 

Apr.,  1917. 

Wartime  employment<of  women  in  the  metal  trades,  Boston,  July,  1918. 


New  York.  Mayor's  Committee  on  National  Defense.  Report  of  the  Committee 
in  industry  and  emploj^ment.     New  York,  1917. 

New  York  (State).  Department  of  Labor.  Industrial  Commission.  Bureau  of 
Statistics  and  information.  European  regulations  for  the  prevention  of 
occupational    diseases. 

.  Albany,  1916.  (In:  New  York  (State)  Department  of  Labor.  Indus- 
trial commission.     Special  bulletin  No.  77.) 

New  York  State  Bureau  of  Inspection.  Health  hazards  of  the  cloth  sponging 
industry.     New  York,  1918. 

New  York.  Legislature.  A  bill  to  provide  for  men  disabled  in  industry  to  take 
special  training  at  state  expense.     Assembly  bill  No.  1907. 

OcHSNER,  A.  J.     Infections  following  injuries.     Railway  Surgical  Journal,  Chicago, 

1917,  xxiii,  321-326. 
Ogden,  C.  K.     Industrial  fatigue.     Nineteenth  Centurj^,  New  York,  1917,  Ixxxi, 

413-433. 
Oldright.     International  congress  of  diseases  of  labor.     Public  Health  Journal, 

Toronto,  1916,  vii,  440. 
Oliver,  Sir  Thomas.     "Occupations,  from  the  Social,    Hygienic   and   Medical 

Points  of  View."     Cambridge,  1916. 
.     The  hygiene  of  occupation  during  the  war.     Medical  press  and  Circular, 

London,  1917,  ciii,  322-346. 
Oppenheim,     M.     Hautschadigungen     in     Munitionsfabriken     mit     besonderer 

Berucksichtigung  der  Quecksilberwyrkung.     Wiener  klinische  Wochenschrift, 

1915,  xxviii,  1273-1278. 
.     tjber   die    Hauschadigungen   der    Munitionsarbeiter.     Wiener  Klinisch 

Wochenschrift,    1917,   xxx,    544. 
Ordway,  Thomas.     Occupational  diseases  due  to  radium.     Journal  of  the  Ameri- 
can Medical  Association,  Chicago,  1916,  Ixvi,  1-6. 


BIBLIOGRAPHY  817 

Outlook  (the)  for  disabled  workmen.     Travelers'  Standard,  Hartford,  1918,  vi, 

56-59. 
Openings  in  Industry  suitable  for  disabled  sailors  and  soldiers.     Fifteen  reports 

prepared  by  Ministry  of  Labor  and  Ministry  of  Pensions,  British  Government, 

1917.     His  Majesty's  stationery  office,  London. 

Parlett,    E.    M.     Health   and   welfare   of   the   railroad   employee.     University 
Gazette,  Baltimore,  1917,  iv,  161-166. 

Patterson,    Francis  D.     Laws  of  Pennsylvania  relating  to  industrial  hygiene. 
Pennsylvania  Medical  Journal,  Athens,  1916,  xx,  6-13. 

.     Prevention  of  occupational  diseases  and  industrial  accidents.     Pennsyl- 
vania Medical  Journal,  Athens,  1916,  xix,  581. 

.     The  relation  of  the  physician  to  some  of  the  problems  of  modern  industry. 

Medicine  and  Surgery,  St.  Louis,  1917,  i,  719-726. 

.     The  physical  reconstruction  and  industrial  rehabilitation  of  the  wounded 

and  diseases.     Medicine  and  Surgery,  St.  Louis,  1918,  ii,  127-135. 

Industrial  training  for  the  wounded.     Annals  of  the  American  Academy 


of  Political  and  Social  Science,  Concord,1918,  Ixxx,  No.  169,  pp.  40-42. 
Pearson,  Robert  H.     "Occupational  Diseases."     New  York,  1915. 
Peri,   A.     Intorno  ad  un  ernia  inguinale  attribuita  ad  infortunio  sul  lavoro. 

Cesalpino,  Arezzo,  1915,  xi,  121,  229,  334,  355. 
Periodic  examination  of  Health  department  employers.     Journal  of  American 

Medical  Association,  Chicago,  1917,  Ixviii,  2004. 
Periodical  examinations  now  routine.   New  York  Health  department  employees 

find  the  practice  in  their  interest.     Modern  Hospital,  St.  Louis,  1917,  viii,  106. 
Pesl,  D.     Leitsatze  iiber  Massnahmen  zur  Verbesserung  der  Lage  der  Heimar- 

beiterinnen.     Munchen  medicinische  Wochenschrift,  1917,  Ixiv,  971. 
PicciNiNi,  P.     Polveri  e  casami  di  saggina  in  rapporto  alia  igiene  del  vavore  degli 

scopai.     Rivista  d'Igiene  e  Sanita  Pubbica,  Roma,  1918,  xxix,  1-8. 
Plummer,  S.  C     Relative  importance  of  strain  and  anatomical  predisposition  in 

causation  of  hernia.     Chicago  Medical  Record,  vol.  xxxvii,  p.  307. 
Pometta,    D.     Gewerbevergiftungen    und    Berufskrankheiten.     Correspondenz- 

Blatt  fur  Schweizer  Aerzte,  Basel,  1917,  xlvii,  147-158. 
Post,  W.  E.     Some  phases  of  medical  supervision  of  employees.     Medicine  and 

Surgery,  St.  Louis,  1917,  i,  772-776. 
Powell,    T.    R.     Workmen's   compensation  acts.     Political  Science   Quarterly, 

New    York,  1917,  xxxii,  542-569. 
Price,  George  M.     Cloak,  suit,  skirt,  dress  and  waist  industries.     Development 

of  the  welfare  work  of  the  joint  board  of  sanitary  control  of  New  York  in  cer- 
tain industries.     Modern  Hospital,  St.  Louis,  1916,  vii,  111-114. 
.     Employment  of  women  in  chemical  industries.     Survey,  New  York, 

1918,  xli,  345-347. 
.     Medicine  and  the  industries.     Journal  of  Sociologic  Medicine,  Easton, 

1917,  xviu,  134-139. 
.     Practical  standards  for  factory  sanitation.     American  Journal  of  Public 


Health,  Concord,  1918,  viii,  288-290. 
Prosser,  Chas.     Rehabilitation  of  industrial  disabled.     Testimony  given  before 

the  joint  committee  on  education  and  labor  of  the  Senate  and  the  House  of 

Representatives    in    hearing  on    Bankhead-Smith   bill,    Dec.    10-12.,   1918, 

Congressional    Record. 
R.   Merkblatt  fiir  Fabriken  in  denen  Trinitrotoluol  hergestellt  oder  verarbeitet 

wird.     Midizinische  Klinik,  Berlin,  1917,  xiii,  1281. 
52 


818  INDUSTRIAL    MEDICINE    AND    SURGERY 

Rand,  W.  H.     Industrial  accidents  and  occupational  diseases.      Medical  Council, 

Philadelphia,  19.18,  xxiii,  827-830. 
.     Latest  feature  in  the  diagnosis  and  prevention  of  some  of  the  occupational 

poisonings.     American  Journal  of  Public  Health,  Concord,  N.  H.,  1916,  vi, 

830-835. 

Missing  links  in  the  chain  of  evidence  concerning  occupational  diseases. 


American  Journal  of  Public  Health,  Concord,  1917,  835-839. 
Rand  Mines,  Limited.     Annual  report  of  the  department  of  sanitation  for  the  year 

1916.  Johannesburg,  1917. 

Redfield,  W.  C.     The  wasters  of  the  world.     American  Journal  of  Public  Health, 

New  York,  1916,  vi,   18-27. 
Redwat,  J.  W.     Dust  and  miners'  tuberculosis.     Medical  Times,  New  York,  1918, 

xlvi,  100. 
Rehabilitating  the  tuberculous  soldier  and  worker.     Modern  Hospital,  St.  Louis, 

1918,  xi,  46-48. 
Rehabilitation    of    injured    workmen    in    Wisconsin.      Monthly    Labor    Review, 

Washington,  1918,  vii,  No.  3,  pp.  85-87. 
Reports   of   federal   and   state  workmen's   compensation   experience.     Monthly 

Labor  Review,  Washington,  1919,  viii,  No.  3,  p.  250-264. 
Reilly,  J.  J.     Medical  services  at  Hog  Island.     New  York  Medical  Journal, 

1918,  cviii,  881. 
Report  of  committee  on  safety  and  health.     National  Association  of  Corporation 

Schools,  Pittsburgh,  May  31,  1916. 
Reports  of  Welfare  and  EfRciency  Conferences,   Dept.  of  Lab6r  and  Industry, 

Pennsylvania,  1916,  1917,  1918. 
Reineking,   H.     Hydrocele  and  orchites;  their  relation  to  trauma.     American 

Journal  of  Surgery,  New  York,  1916,  xxx,  229-231. 
Riddle,  S.   S.     Pennsylvania's  part  in  the  national  plan  for  rehabilitating  and 

placing  in  industry  soldiers  and  sailors  disabled  in  war  service.     Bulletin 

Penn.  Dpt.  Labor  and  Industry,  1918. 
RiGBY,    Elfrida.     Placing    cripples   in  industry.     Modern  Hospital,  St.  Louis, 

1917,  ix,  417. 

Ring,  D.     Sanitation  of  factories.     Public  Health  Journal,  Toronto,  1919,  viii, 

266-271. 
RiSLEY,  E.   H.     The  importance  of  the  workingman's  hand  and  its  treatment 

when  involved  in  sepsis.     Dominion  Medical  Monthly,   Toronto,   1918,  li, 

1-11. 
RrxFORD,  E.     Surgical  aspects  of  industrial  insurance.     Journal  of  the  American 

Medical  Association,  Chicago,  1916,  Ixvii,  1004-1011. 
Roach,    J.     Hygienic  and  sanitary  equipment.     Industrial  Management,   New 

York,    1917,   liv,   20-29. 
Roberts,  J.  E.  H.     Workmen  and  hernia.     Lancet,  London,  vol.  ii,  p.  1503. 
Robertson,  V.    Otis.     Rehabilitation  of  industrial  cripples  in   Massachusetts. 

American  Labor  Legislation  Review,  New  York,  1919,  ix,  126-129. 
Robinson,   D.  E.  and  J.  G.  Wilson.     Tuberculosis  among  industrial  workers, 

report  of  an  investigation  made  in  Cincinnati,  with  special  reference  to 

predisposing  causes,   Washington,   1916.     (Public  Health  Bulletin,  No.  73.) 
Rosey,  C.  S.     The  feeble-minded  in  industry.     Modern  Hospital,  St.  Louis,  1917, 

ix,  204-206. 
.     Mental    examination    for    employees.     Industrial    Management,    New 

York,  1917,  liv,  359-365. 
Routsong,  R.  C.     Workshop  education  in  hygiene.     American  Journal  of  Public 

Health,  New  York,  1916,  vi,  139-142. 


BIBLIOGRAPHY  819 

RuBiNow,    I.    M.     Health   insurance,   practice   of  medicine   and   public   health. 

Public  Health  Journal,  Toronto,  1917,  viii,  318-327. 
.     Survey    of    spreading    health    insurance    movement.     Public     Health 

Journal,  Toronto,  1917,  viii,  92-100. 

Safford,  M.  V.  Influence  of  occupation  on  health  during  adolescence  (cottf)n 
industry).     Washington,  1916.     (U.  S.  Public  Health  Bulletin,  No.  78.) 

Savard.  Remarques  sur  I'inspection  medicale  des  industries.  Bulletin  meflical 
de  Quebec,  1916,  xviii,  159-163. 

ScARBURGH,  R.  S.  Welfare  work  of  the  New  York  telephone  company.  Modern 
Hospital,  St.  Louis,  1917,  ix,  62-65. 

Scars,  the,  of  war;  the  nation's  duty  to  its  disabled  men.  Ex-service  Man, 
London,  1919,  i.  No.  19. 

Schedule  for  hand  injuries  under  the  New  York  law.  Monthly  Labor  Review, 
Washington,  1919,  viii.  No.  3,  pp.  248-249. 

ScHERESCHEWSKY,  J.  W.  Health  of  garment  workers:  the  relation  of  economic 
status  to  health.     Public  Health  Reports,  Washington,  1916,  xxxi,  1298-1305. 

.  Industrial  hygiene.  A  plan  for  education  in  the  avoidance  of  occupa- 
tional diseases  and  injuries.  Washington,  1915.  Reprinted  from  Public 
Health  Reports,  No.  302,  Oct.  1,  1915. 

.     Industrial  insurance.     Medical  examination  of  employees  and  prevention 

of  sickness  and  its  proper  function.  Washington,  1914.  Reprinted  from 
Public  Health  Reports,  No.  197,  June  5,  1914. 

.     Maintenance  of  health  in  industries,  its  relation  to  adequate  production 

of  war  materials.     Public  Health  Reports,  Washington,  1917,  xxxii,  835-839. 

.     Methods  of  prevention  and  control  of  disease  in  the  war  industries. 

Medical  Insurance  and  Health  Conservation,  Dallas,  1917-1918,  xxvii,  408- 
411. 

.  The  occupational  hazard  in  the  chemical  industry;  the  need  for  prophy- 
laxis.   Journal  of  Industry  and  Engineering  Chemistry,  Easton,  1916,  viii,  1055. 

.     A  plan  for  education  in  industrial  hygiene  and  the  avoidance  of  occupa- 


tional complaints.     American  Journal  of  Public  Health,  Concord,  1916,  vi, 
1031-1038. 

— .     The  relation  of  the  industrial  physician  to  the  problems  of  modern 
industry.     Journal  of  Sociologic  Medicine,  Easton,  1917,  xviii,  140-150. 

Trinitrotoluol:  practical  points  in   its  safe   handling.     Public   Health 


Reports,  Washington,  1917,  xxxii,  1919-1926. 

Scott,  A.     Deformity  as  a  cause  of  industrial  disablement  or  inefficiency.     Journal 
of  State  Medicine,  London,  1916,  xxiv,  40-60. 

Selby,  S.  D.     Medical  service  in  the  conservation  of  industrial  man  power.     Jour- 
nal of  American  Medical  Association,  Chicago,  1918,  Ixxii,  333-336. 

.     A  proposed  bureau  of  industrial  safety,  sanitation  and  hygiene  to  be 

maintained  on  the  mutual  plan.     American  Journal  of  Public  Health,  Concord, 
1916,  vi,  1187-1189. 

.     Relation  of  industry  to  health  department.     Ohio  State  Board  of  Health 

Bulletin,  Columbus,  1917,  viii,  66-71. 

Physicians  in  industry.     Report  of  U.  S.  Public  Health  Service,  1918. 


Seligmann,  Carrie  M.     A  workroom  for  cripples.     American  Journal  of  Care 

for  Cripples,  New  York,  1916,  iii,  164-166. 
Semple,  Mrs.  S.    The  health  hazards  to  women  as  the  result  of  the  war  emergency. 

Proceedings  of  the  Conference  of  Industrial  Physicians  and  Surgeons,  Athens, 

1918,  vi,  3-7. 


820  INDUSTRIAL    MEDICINE    AND    SURGERY 

Shadwell,  a.     Welfare  of  factory  workers.     Edinburgh  Review,  New  York,  1916, 

ccxxiv,  361-381. 
Sherman,  Wm.  O'Neill.     Carrel  method  of  wound  sterilization ;  its  use  in  military, 

industrial,  and  civil  practice.     Surgery,  Gynecology  and  Obstetrics,  Mch.  ,1917. 
Shie,  Marvin  D.     Wound  infection  among  lathe  workers;  an  investigation  into 

some  of  the  factors  causing  wound  infection  in  industrial  surgery  and  methods 

of  obviating  them.     Journal  of  the  American  Medical  Association,  Chicago, 

1917,  Ixix,  1927-1930. 

Shoudy,  Loyal  A.  Medical  supervision  of  workers  and  its  relation  to  the  preven- 
tion of  industrial  accidents.  Journal  of  Sociologic  Medicine,  Easton,  1917, 
xviii,  56-75. 

.     The  nation's  neglect — The  failure  to  reconstruct  and  rehabilitate  the 

wounded  in  industry.  In :  Proceedings  of  the  Sixth  Conference  of  Industrial 
Physicians  and  Surgeons,  Harrisburg,  1918,  pp.  10-13. 

Silver,  David.  The  problem  of  the  artificial  arm.  Journal  A.  M.  A.,  vol.  Ixxi, 
pp.  181-182. 

Slaviero,  G.  Dialcune  affezioni  frequenti  nei  coltivatori  della  canapa.  Lavoro, 
Milano,  1915,  viii,  289-300. 

Smith,  L.  H.  The  blood  of  workers  in  trintrotoluene.  Journal  of  the  American 
Medical  Association,   Chicago,   1918,  Ixx,  231. 

Smith,  W.  B.  Industrial  hernia.  California  State  Journal  of  Medicine,  San 
Francisco,  1916,  xiv,  351. 

Smyth,  H.  F.     Dust  in  industry.     Scientific  Monthly,  New  York,  1918,  vi,  56-64. 

Snow,  W.  F.'and  W.  A.  Sawyer.  Venereal  disease  control  in  the  army.  Journal 
A.  M.  A.,  vol.  Ixxi,  pp.  456-462. 

Social  insurance — laws  re  workmen's  compensation  during  1917 — also  health  in- 
surance.    American  Labor  Legislation  Review,  New  York,  1917,  vii,  573-596. 

Society  of  Medical  Jurisprudence.  Report  of  the  committee  on  industrial  insur- 
ance, Feb.  2,  1917,  New  York,  1917. 

Southard,  W.  F.  Necessity  for  efficiency  in  examination  of  eyes  and  ears  of 
railroad  employees.     Pacific  Medical  Journal,  San  Francisco,  1916,  lix,  88-95. 

Spooner,  H.  G.  Industrial  fatigue  in  its  relation  to  maximum  output.  London, 
n.d. 

Staebler,  Anna  M.  Conservation  of  man  power  in  industry.  Boston  Medical 
and  Surgical  Journal,  1918,  clxxviii,  868-871. 

Stearns,  H.  Neglected  causes  'of  fatigue.  New  Republic,  New  York,  1917, 
x,  347-350. 

Stengel,  A.  E.  Aid  from  the  medical  profession  in  the  prevention  of  disease  in  the 
war  industries.     Medical  Insurance  and  Health  Conservation,  Dallas,  1917- 

1918,  xxvii,    413-414. 

— .     Relation  of  extreme  temperatures  to  the  efficiency  of  the  workman. 

Second  Conference  Industrial  Physicians,  Harrisburg,  May  18,  1916. 

Stern,  F.  and  G.  T.  Spitz.  Food  for  the  worker — food  values  and  the  cost  of 
menus  and  recipes  for  seven  weeks.     Boston,  1917. 

Stewart,  I.  S.  Notes  on  the  sanatorium  treatment  of  industrial  patients.  Prac- 
titioner, London,  1916,  xcvii,  554-567. 

Stirling,  W.  Fatigue  and  its  effects  on  industry  and  efficiency.  Medical  Press 
and  Circular,  London,  1916,  n.s.,  cii,  428. 

Stokes,  Chas.  F.  The  military,  industrial  and  public  health  features  of  narcotic 
addiction.     Journal  A.  M.  A.,  vol.  Ixx,  No.  11,  p.  776. 

Stone,  Gilbert.     "Women  War  Workers."     London,  1917. 

Strauss  P.  Le  travail  feminin  dans  les  usines  de  guerre.  Revue  Philanthro- 
pique,  Paris,  1917,  xxxviii,  113-121. 


BIBLIOGRAPHY  821 

Stroud,  R.     Some  statistics  gathered  from  physical  examination  of  employees. 

Southwestern  Medicine,  El  Paso,  1918,  ii,  23-26. 
Summary  of  findings  and  recommendations  of  the  Ohio  health  and  old-ageinsurance 

commission.     Monthly   Labor    Review,    Washington,    1919,  viii,  No.  3,  pp. 

264-282. 
Symonds,  C.  p.     Notes  on  a  case  of  traumatic  hernia  of  the  diaphragm  proving 

fatal  seven  hours  after  the  wound.     Journal  of  the  Royal  Medical  Corps, 

London,  1917,  xxxix,  349-353. 
Symposium  on  Reconstruction  and  Rehabilitation  of  Disabled  Soldiers.      Journal 

A.  M.  A.,  July,  1918. 
Syrup,    Friedrich.     Die    Fursorge    fiir    Kriegsverletzte    gewerbliche    Arbeiter, 

Dusseldorf,  1916. 

Tapt,  Jessie.     Mental  pitfalls  in  industry:  and  how  to  avoid  them.     Medicine 

and  Surgery,  St.  Louis,  1917,  i,  679-685. 
Taussig,    Frances.      Making    dependents    self-supporting.     Modern    Hospital, 

St.  Louis,  1917,  viii,    418-419. 
Tedeschi,    E.     II    pricolo    tubercolare    negli    stabilimenti    industriali.     Igiene 

Moderna,    Genova,    1918,    xi,    126-130. 
Thibierge,  G.     Le  "bouton  D'huile"  des  tourneurs  d'obus  au  point  vue  clinique 

et  medico-legal.     Bulletin  de  I'Academie  de   Medicine,   Paris,    1918,  Ixxix, 

208-211. 
Thompson,  W.  G.     Industrial  hygiene  in  war  time.     American  Journal  of  Public 

Health,  Concord,  1918,  viii,  27-33. 
.     Industrial  hygiene  in  war  time.     Medical  Insurance  and  Health  Conser- 
vation, Dallas,  1918,  xxvii,  223-227. 
.     The  menace  of  the  dusty  trades.     American  Journal  of  Public  Health, 

Concord,  1917,  vii,  737-741. 
.     New  poisons  in  war  industries.     New  York  Medical  Journal,  1918,  cvii, 

717. 

The  relation  of  the  hospital  and  dispensary  to  occupational  diseases. 


American  Journal  of  Public  Health,  Concord,  N.  H.,  1916,  vi,  982-986. 
Thomson,  Elnora  E.     Occupation  and  its  relation  to  mental  hygiene.     Modern 

Hospital,  St.  Luois,   1917,  vui,    397. 
ToIjMAn,  W.  H.     Une  usine  modele  au  point  de  vue  de  I'hygiene  industrielle. 

Annales  d'Hygiene,  Paris,  1916,  4  s.,  xxv,  5-27. 
Transactions  of  American  Association  of  Industrial   Physicians  and   Surgeons, 

1916,  1917,  1918,  Chicago. 

Transactions    Industrial    Hygiene    Section,    American    Journal    Public    Health, 

Concord,  1916,  1917,  1918. 
Transactions  Health  Betterment  Section,  National  Safety  Council,  Chicago,  1916, 

1917,  1918. 

Trask,  John,  W.     Hospital  and  medical  treatment  of  injured  civil  employees  of  the 

United  States.     Interstate  Medical  Journal,  St.  Louis,  1918,  xxv    551-555. 

Tuck,  D.  H.     The  lighting  of  industrial  establishments.     Medical  Officer,  London, 

1918,  XX,  29. 

.     The  lighting  of  industrial  establishments;  the  need  for  supervision  with  a 

suggested  system  of  maintenance  rating  for  artificial  fight  equipment.     Public 

Health  Reports,  Washington,  1917,  xxxu,  1761-1764. 
Turpin,  M.  C.     Where  welfare  of  employees  is  considered  of  great  importance. 

Modern  Hospital,  St.  Louis,  1917,  vii,  300-303. 
Two  new  clinics  for  occupational  diseases.     Modern  Hospital,  St.  Louis,  1917,  viu, 

154. 


822  INDUSTRIAL    MEDICINE    AND    SURGERY 

Underlying  principles  of  workmen's  compensation  laws.     Journal  of  American 
Medical  Association,  Chicago,  1917,  Ixviii,  1822-1823. 

Union    of    South    Africa.      Miners'    Phthisis    Prevention    Committee.      General 
report.     Pretoria,  1916. 

United  States  Department  of  Labor  Statistics.     Effect  of  the  air  hammer  on  the 
hands  of  stone-cutters.     Washington,    1918.      (Bulletin   No.   236.) 

.     Effect  of  workmen's  compensation  laws  in  diminishing  the  necessity 

of  industrial  employment  of  women  and  children.     Washington,  1917. 

.     Hours,  fatigue  and  health  in  British  munition  factories,  reprints  of  the 

memoranda  of  the  British  health  of  munition  workers  committee.     Washing- 
ton, 1917. 

.     Industrial  experience  of  trade  school  girls  in  Massachusetts.     Washing- 
ton, 1917. 

.     Street  railway  employment  in  the  United  States.     Washington,  1917. 

.     Wages  and  hours  of  labor  in  the  boot  and  shoe  industry;  1907  to  1916. 

Washington,   1918.      (Bulletin   No.  232.) 

Welfare  work  in  British  munition  factories.     Washington,  1917. 


United  States,  65th  Congress.  2d  Session.  A  bill  to  provide  for  the  promotion  of 
vocational  rehabilitation  of  persons  disabled  in  industry  or  otherwise  and  their 
return  to  civil  employment.     Washington,  1918.     (H.  R.  12880.) 

Van  der  Heijden,  H.  N.     De  arb eiders verzorging  en  het  hospitaalwezen  in  de 

boven-landen  van  Benkoelen.     Soerabaia,    1916. 
Van  Sickle,  F.  L.     Discussion  of  the  two  years'  experience  with  the  workmen's 

compensation  law  of  Pennsylvania  from  the  viewpoint  of  the   Industrial 

physician  and  surgeon.     Journal  of  Sociologic  Medicine,  Easton,   1918-19, 

xix,  208-219. 
.     Social    insurance  against  accidents.     (Workmens  compensation  laws.) 

Journal  of  Sociologie  Medicine,  Easton,  1916,  xvii,  285-307. 
Varrier-Jones,  p.  C.     A  rational  scheme  for  the  after-care  of  the  consumptive 

working  man.     British  Journal  of  Tuberculosis,  London,  1917,  xi,  21-23. 

.     Tuberculosis  and  the  working  man.     Cambridge,  1916. 

Vbrco,    J.    C.     An  unusual   case   of   occupation  neurosis.     Medical  Journal  of 

Australia,  Sydney,  1917,  ii,  50. 
Vest,  W.  E.     The  future  of  railway  medicine  and  surgery.     Southern  Medical 

Journal,  Birmingham,  1918,  xi,  796-798. 
ViciNi,  G.     A  proposito  del  lavoro  della  donna.     Cesalpino,  Arrezzo,  1917,  xiii, 

61-65. 
ViGNE,  A.     Del'aptitude  au  travail  des  tuberculeaux  sa  valeur,  son  utilisation 

au  cours  de  la  crise  economique  actuelle.     Paris  Medical,  1917,  xxi,  284—290. 
Vocational  education  and  employment  of  the  handicapped,  with  special  reference 

to  crippled  soldiers.     (A  bibliography,  Sept.,  1917,  Bureau  of  Statistics,  U.  S. 

Dept.  of  Labor. 

Walker,  Anne  Kendrick.     Looking  beyond  the  door  of  welfare  service  in  the 

department  store.     Modern  Hospital,  St.  Louis,  1916,  vii,  119-122. 
Walsh,  Joseph  J.     Mine  ventilation.     Journal  of  the  American  Society  of  Heating 

and  Ventilating  Engineers,  New  York,  1917,  xxui,  499-503. 

.     Mining  and  mine  ventilation.     London,  1917. 

Walsh,  William  H.     Welfare  and  efficiency  achieved  at  the  same  time.     Modern 

Hospital,  St.  Louis,  1916,  vii,  115-118. 
Walter,  Henriette  Rose.     Munition  workers  in  England  and  France.     New 

York,  1917. 


BIBLIOGRAPHY  823 

Waknshuis,  F.  C.     a  discussion  of  fifteen  hundred  industrial  injuries.     Journal 

of  the  Michigan  State  Medical  Society,  Grand  Rapids,  1917,  xvi,  490-493. 
Waeren,  B.  S.     Sickness  insurance:  its  relation  to  public  health  and  the  common 

welfare.     Washington,   1915.     Reprinted  from   Public  Health  Reports,  No. 

250,  January  8,  1915.    -  - 
-.     Statistics  of  disability,  a  compilation  of  some  of  the  data  available  in  the 

United  States.     Public   Health   Report,    Washington,    1916,   xxxi,   989-999. 
Warren,  B.  S.  and  Edgar  Sydenstricker.     Health  insurance:  its  relation  to  the 

public  health.     (Public  Health  Bulletin,  No.  78.) 
.     Morbidity  statistics  of  war  industries  needed.     Public  Health  Reports, 

Washington,   1918,  xxxiii,    127-132. 
Watkins,  J.  A.     Mitigation  of  the  heat  hazard  in  industries.     Public  Health 

Reports,  Washington,  1917,  xxxii,  2111-2121. 
Watt,  J.  H.  and  others.     Miners'  phthisis:  recent  investigations.     II.  Changes 

produced   in   the    silicotic    lung   by    infective    processes;   tuberculo-silicotic 

changes.     Medical  Journal  of  South  Africa,  Hohannesburg,  1916,  xii,  15-22. 
Watters,  L.  L.     Emergency  hospitals  for  industrial  plants.     Modern  Hospital, 

St.  Louis,  1917,  viii,  107-111. 
Webb,  Beatrice.     Health  of  working  girls.     A  handbook  for  welfare  supervisors 

and   others.     London,    1917. 
Wegmann,     H.     Zur    Pneumonokoniose    der    Metallschleifer.     Correspondenz- 

Blatt  fiir  Schweizer  Aerzte,  Basel,  1917,  xlvii,  526-528. 
Weisman,  Charles.     Studies  in  vocational  diseases.     The  effect  of  gas-heated 

appliances  upon  the  air  of  work-shops.     Washington,  1917.     (Public  Health 

Bulletin  No.  81.) 
WeKare  work.     Stories  from  various  industries.     Modern   Hospital,   St.  Louis, 

1916,  vii,  133-166. 

West,  F.  C.  The  medical  department  of  a  modern  industrial  plant.  Boston 
-Medical  and  Surgical  Journal,  1916,  clxxv,  914-915. 

West,  F.  O.  The  manufacture  of  picric  acid  from  the  medical  standpoint.  Jour- 
nal of  Industrial  and  Engineering  Chemistry,   Easton,    1917,  ix,   303-305. 

Wheller,  R.  M.  The  necessity  of  preliminary  and  periodic  physical  examination 
of  R.  R.  employees  as  a  means  to  greater  efficiency.  Railway  Surgical  Journal, 
Chicago,  1916-17,  xxiii,  203-210. 

Wheelock,  W.  a  discussion  of  lead  poisoning  on  examination  in  thirty-two 
industrial  plants,  complying  with  the  occupational  diseases  law,  in  the  state  of 
Illinois.     Chicago  Medical  Recorder,  1917,  xxxix,  303-310;  370-376. 

White,  J.  P.  Compulsory  physical  examination.  In:  Proceedings  of  the 
Conference  of  Social  Insurance,  1916,  Washington,  1917,  p.  314-316,  335-347. 

White,  W.  H.  Physical  examination  and  medical  supervision  of  employees. 
In:  Proceeding  of  the  Conference  of  Social  Insurance,   1916,   Washington, 

1917,  p.  327-347. 

WiLBERT,  M.  I.  Occupational  intoxications.  PubHc  Health  Reports,  Washington, 
1916,  xxxi,  763. 

Wisconsin,  permanent  partial  disabilities.     Bulletin  of  Industrial  Commission,  1917. 

Williams,  A.  Industry  and  the  health  of  the  employee.  Journal  of  the  National 
Dental  Association,  Huntington,  1918,  v,  951-955. 

Williams,  T.  A.  The  traumatic  neurosis;  nature  and  management;  some  forensic 
aspects  shown  in  the  case  of  Hill  vs.  Chicago,  Milwaukee  and  St.  Paul 
R.  R.  Co.  Journal  of  the  American  Institute  of  Criminal  Law  and  Crimi- 
nology, Chicago,  1917,  vii,  689-701. 

Williams,  Whiting.  Factory,  family  and  firing  line.  Cleveland  Topics,  May  26, 
1917. 


824  BIBLIOGRAPHY 

Williams,  Whiting.  Human  relations  in  industry.  National  Safety  Council, 
Chicago,  1917. 

Wilson,  H.  M.  Inspection  and  schedule  rating  of  coal  mines  as  a  means  of  pre- 
venting mine  accidents.  In:  Proceedings  of  the  Conference  of  Social  Insur- 
ance, 1916,  Washington,  1917,  p.  273-291. 

WiNSLOw,  C.  E.  A.  The  effect  of  atmospheric  conditions  upon  fatigue  and  effi- 
ciency.    American  Journal  of  Public  Health,  Concord,  1917,  827-834. 

Wittgen,  Beitrag  zu  den  Gesundheitsverhaltnissen  der  Arbeiterinnen  in  Lumpen- 
sortieranstalten.     Zentralblatt  f  tir  Gewerbehygiene,  Berlin,  1915,  iii,  245-251. 

Wood,  G.  H.  Arrangement  of  treatments  in  industrial  work.  Hospital  Manage- 
ment, vol.  V,  No.  5. 

Women  in  Industry  Service,  U.  S.  Dept.  of  Labor,  Standards  governing  the 
employment  of  women,  1918-1919. 

Woodbury,  R.  M.     Social  insurance — an  economic  analysis,  New  York,  1917. 

Wright,  A.  H.  Work,  fatigue  and  rest.  Canadian  Practioner  and  Review, 
Toronto,    1917,  xlii,   231-236. 

Wright,  W.  The  hospital  and  industrial  hygiene.  American  Journal  of  Public 
Health,  Concord,  1917,  vii,  949-952. 

WuRTZ.  Sur  la  suppression  du  chiffonnage  &  Paris.  Bulletin  de  I'Acad^mie  de 
Medicine,  Paris,  1916,  3  s.,  Ixxx,  429-434.     492-503. 

Yaple,  W.  D.     Commission  supervision  of  industrial  hygiene.     American  Journal 

of  Public  Health,  New  York,  1916,  vi,  369-373. 
Young,  A.  H.     Practical  aspects  of  the  safety  movement.     Industrial  Mangement, 

New  York,  1917,  liv,  30-35. 


INDEX 


Abditction  and  adduction  of  wrist,  558      Adduction  and  abduction  of  wrist,  558 


wrist,  in  action,  559 
Abrasions  and  blisters  on    feet,  treat- 
ment of,  661 
Accident  carriers,  328 
prevention  man,  486 
rate,  influence  on,  of  new  employees 

and  speeding-up,  351 
report  record,  121,  122,  123 
surgery,  sources  of,  484 
Accidents,  coincidence  of,  with  disease, 
707 
due  to  physical  or  mental  condition  of 

employee,  328 
in  elevator  shafts,  321 
in  home,  338 

treatment  of,  22 
industrial,  division  of,  319 
prevention  of,  318,  319,  486 
and  recurrences,  25 
depends  upon  inspection  and  edu- 
cation, 339 
due  to  disaster,  331 

to  physical  or  mental  condition 
in  employee,  328 
employees'  co-operation  in,  134,  341 
in  cerebrospinal  syphilis,  330 
in  epilepsy,  329 
in  fire,  331 
in  heart  disease,  330 
in  plant,  138 

inspectors  of  safety  methods  in,  341 
major,  320 
minor,  331 
physical  examination  of  employees 

for,  328,  329 
safety  appliances  attached  to  em- 
ployee, 326 
on  machinery,  324 
Acetylene  gas  installations,  health  haz- 
ard regulations  for,  247 
Acid,  carbolic,  as  disinfectant,  161 
Activities  of  employees'  service  depart- 
ment, 19 
of  industry,  prevention  in  relation  to, 
139 


Adequate  ventilation,  155 

Adjuncts  to  health  supervision,  services 

of,  19 
Ague,  zinc,  218 
Aid,  first.     See  First  aid. 
Air,  bad,  151,  152 
functions  of,  152 

factors  dependent  on,  153 
motion,  155 

purity  of,  and  cleanliness  of  work- 
rooms in  prevention  of  industrial 
poisoning,  236 
Alcoholism,  predisposing  factor  to  tu- 
berculosis, 433 
Aluminum  sulphate  and  formalin-Hme 
method  of  evolving  formaldehyd  gas, 
158 
Americanization   of   foreign   employee. 

769 
Ammonia,  aromatic  spirits  of,  use  of,  500 
production  of,  health  hazard  regula- 
tions for,  247 
Amputated  cases  exercising  stump,  563 

teaching  to  use  artificial  legs,  656 
xA.mputations,  639 

adhesive  plaster  method  in,  642 
artificial  limbs  to  accustom  patients 

to  use  of  stumps  in,  654 
finger,  641 
of  lower  extremity,  647 

care  of  stump  after,  650-652 
important  points  in  operation  in, 

650 
preferable  sites  of,  648,  649 
of  upper  extremity,  643 

preferable  sites  of,  644-646 
traction  to  skin  to  prevent  re- 
traction in,  643,  644 
testing  of  joint  motions  after,  653 
Ankle,  eversion  and  inversion  of,  561 
Anti-accident  propaganda,  339 
Antiseptics  used  in  emergency  surgery, 

515 
Antitoxin,  tetanus,  in  emergency  surg- 
ery, 522,  523 


825 


826 


INDEX 


Apoplexy,  accident  prevention  in,  329 

traumatic,  medicolegal  aspects  of,  736 
Appendicitis,     traumatic,     medicolegal 

aspects  of,  736 
Applicants  for  work,  information  record 
of,  117 
medical  examination  of,  22,  27,  86, 
87,  134,  359,  370 
do   they   object  to   examina- 
tions, 381 
fitting  disabled  to  jobs,  382 
percentage  of  rejects,  384 
reasons  for  examination,  372 
rejection  standards,  377 
should  diseased  conditions  be 

explained,  380 
what  becomes  of  rejects,  383 
when  to  examine,  371 
Army,    industrial,   health   of,   plan  for 
supervision  of,  465 
problem  of  tuberculosis  in,  467 
Aromatic  spirits  of  amnaonia,  use  of,  500 
Arsenic,  health  hazards  in  use  of,  regu- 
■     lations  for,  271 
pock,  219 
poisoning,  219 

in  American  trades,  220 
in  English  trades,  219 
Arseniuretted  hydrogen,  health  hazard 

regulations  in,  271 
Artificial  arm,  temporary,  654 
breathing.     Schafer  method  for,  249 
legs,  temporary,  653 
manures,  manufacture  of,  health  haz- 
ard regulations  for,  242 
Assistants,     lay,    number    needed    bj' 

medical  staff,  93 
Associations,  benefit,  employees',  760. 
See  also  Employees'  benefit  associations. 
Athletics,  28 

contests  in,  105,  107 
fields  for,  105 
outdoor,  107 
Author's  first  aid  kit,  498 
Automobile  concern,  medical  attention 
in,  47 

Bacteriological  examinations,  plan 
used  in  large  industry,  73 

Bad  air,  151,  152 

Balkan  frame  for  suspension  traction 
method  of  treating  compound 
fracture  of  humerus,  609 


Balkan    frame   for    traction    and   sus- 
pension in  leg  fractures,  617,  618 
Bandages,  surgical,  481 
Banking  and  loan  service  of  employees, 

31 
Bath  tubs  in  connection  with  medical 

department,  42 
Bed,  stretcher,  use  of  in  army  hospital, 
600 
table  suitable  for  games  or  bed-side 
occupations,  555 
Benefit    associations,    employees,'  760. 
See  also   Employees'   benefit  associa- 
tions. 
Benefits  and  profits  of  medical  depart- 
ment, 79 
and    work    of    human    maintenance 
department,  81,  82 
Benzin  in  industry,  health  hazard  regu- 
lations for,  244 
Bichlorid  of  mercury,  as  disinfectant,  161 
Bleaching  powder,  chlorin  and  its  com- 
pounds, health  hazard  regulations  for, 
238 
Blind  soldiers,  re-education  of,  784 
Blisters  and  abrasions  on  feet,   treat- 
ment of,  661 
Blood  analyses,  plan  used  in  large  in- 
dustry, 73 
transfusion   in   shock    in    emergency 
surgery,  527,  530 
Bone  cysts,  in  open  treatment  of  frac- 
tures, 634 
repair  of,  by  autogenous  graft,  635, 
636 
grafts,  autogenous,  facts  in  repair  of 
fractures  or  bony  defects  by, 
636 
in  open  treatment  of  fractures, 

631-633 
value  of,  in  repairing  bony  de- 
fects, 633 
Boot  and  shoe  industry,  dust  hazards  in, 

208 
Braces  and  supports,  quackery  in,  397 
Brass  casting,  health  hazard  regulations 
in,  269 
founders'  ague,  218 
Brazier's  disease,  218 
Bulb,  wet  and  dry,  for  plant  tempera- 
ture, 153 
Bunions,  treatment  of,  662 
Burns,  paraffin  treatment  of,  537-540 


INDEX 


827 


Cafeteria,   dining  room,   commissary 
and  locker  room,  floor  plan  of,  114 
for  employees,  1 13 
Calcium  oxid  as  disinfectant,  161 
Caliber  of  physicians  employed,  90 
Callosities,  treatment  of,  661 
Cape  used  to  cover  girls  during  physical 

examination,  417 
Carbolic  acid  as  antiseptic,  515 
as  disinfectant,  161 
salve,  danger  in  use  of,  539 
Carbon   bisulphid   in   industry,    health 

hazard  regulations  for,  245 
Carpal  bones,  fractures  of,  614 
Carrel-Dakin  method  in  treatment  of 
infected  compound  fractures,  627 
solution,  preventive  measure  in  acci- 
dents, 333 
Cathartic  habit  among  employees,  425, 

426 
Ceramic  industries,  health  hazard  regu- 
lations in,  267 
Cerebrospinal    syphilis,    accident    pre- 
vention in,  330 
Chemical  industries,  health  hazard  regu- 
lations in,  237 
acetylene   gas   installations, 

247 
ammonia  production,  247 
bleaching    powder,    chlorin 

and  its  compounds,  238 
carbon  bisulphid,  245 
chromium  compounds,  244 
coal  tar  colors  and  organic 

dye-stuffs,  249 
fertilizers  and  artificial  man- 
ures, 242 
hydrochloric  acid,  salt  cake, 
and  soda  industries,  237 
nitric   acid   and  explosives, 

238 
petroleum  and  benzin,  244 
phosphorus,  245 
power  gas  works,  245 
sulphuric  acid  industry,  237 
tar,   coke  and  gas  produc- 
tion, 245 
products  from  distillation, 
248 
trinitrotoluene  in  munition 
work,  238 
Chicago  Industrial  Nurses  Club,  59 
Chief  surgeon,  44 


Children  of  employees,  free  dental  serv- 
ice for,  63 

Chlorin  and  its  compounds,  and  bleach- 
ing powder  industries,  health  hazard 
regulations  for,  238 

Chlorinated  lime  as  disinfectant,  161 

Chromium  compounds  in  industry, 
health  hazard  regulations  for,  244 

Cigar  and  cigarette  manufacture,  health 
hazards  in,  209,  210 

City  health  department  and  plant 
medical  department,  co-operation  be- 
tween, 113 

Clap,  198 

Clavicle,  fractures  of,  606 

modification  of  Sayre  dressing  for, 
607 

Cleanliness  of  workroom  and  purity  of 
air  in  prevention  of  industrial  poison- 
ing, 236 

Cleansing  of  wounds  in  emergency 
surgery,  520 

Clerical  and  filing  room  in  doctor's 
office,  39 

Clothes  hooks  for  employees,  163 

Clothing  of  women  in  industry,  421 

Coal  tar  colors  and  organic  dye-stuffs, 
production  of,  health  hazard  regula- 
tions for,  249 

Coke,  tar  and  gas,  production  of,  health 
hazard  regulations  for,  245 

Cold  and  hot  water  for  employees,  163, 
164 

Colds,  178,  423 

contagiousness  of,  179 

educational  propaganda  on  infectious 

nature  of,  423 
instructions  for  employees  in  treat- 
ment of,  424 

Coincidence  of  accidents  with  disease, 
707 

Colic,  in  lead  poisoning,  215 

Colles'  fracture,  614 

CoUodium,  danger  in  use  of,  534 

Combating  shock,  500 

Commissary,  cafeteria,  dining  and 
locker  rooms,  floor  plan  of,  114 

Committee  on  Factories,  report  of, 
36 

Community  and  housing  ser-sdce  of 
employees,  32 

Compensable  hernia,  690.  See  also 
Hernia,  compensable. 


828 


INDEX 


Compensation  acts,  673 

accident,   American  variations  of, 
674 
British  definition  in,  674 
causes  of,  675 
definition  in,  673 
proof  of,  675 
aggravation  of  injury,  677 
broadening  of  liability   of   British 

Act,  675 
disfigurement,  provision  for,  678 
duties  of  industrial  surgeon  in  rela- 
tion to,  682 
elimination  of  'out  of,'  676 
exclusion  of  disease  by  some  states, 

675 
extension  of  coverage  by   Massa- 
chusetts, 675 
in    relation    to    returned    disabled 

soldier,  685-689 
occupational  disease   as   accident, 

678 
pre-existing  disease  or  injury,  677, 

707 
proximate  causes  of  injury,  676 
refusal   of   medical   instruction   or 

recommendations,  677 
separation  of  accident  and  disease 

in  British,  674 
special  liability  suggested  by  Con- 
necticut commission,  676 
subject  of  hernia,  678 
and  insurance,  272 
and  litigation,  unjust,  reduction  of, 

by  medical  department,  85,  86 
employees',  from  medical  viewpoint, 
667 
Compound  solution  of  cresol  as  disin- 
fectant, 160 
Conditions,  directly  the  result  of  occu- 
pations, treatment  of,  22 
Confidence  of  employees  necessary  to 

success  of  medical  department,  80 
Constipation,  423,  425 

cathartic  habit  in,  425,  426 
prescription  for  fruit  mixture  for,  426 
Constrictor,  u  e  of,  in  hemorrhage,  500 
Contagious  diseases  in  industry,  178 
Contests,  athletic,  105,  107 
Convalescents,   gymnastics  and  games 

for,  564 
Co-operation    of    employees    necessary 
in  preventive  measures,  134,  341 


Corns,  treatment  of,  660 
Cost  of  health  supervision  in  industry, 
94,  96 
of  medical  and  surgical  supervision 
of  employees,  84 
department.     See    Medical   depart- 
ment, cost  of. 
Cresols,  as  disinfectants,  160,  161 
Cripples,  employment  of,  375-377 
Crushes  of  terminal  phalanx,  616 
Cuspidors,  infectious  nature  of  contents 
of,  126 
proper  disinfection  of,  162 


Daily  routine  of  industrial  nurse,  53 
Dakin's  solution  as  antiseptic,  515 
Darkness  breeder  of  accidents,  321 
Death,  impending,  in  emergency  surg- 
ery, 523 
Defective  vision,  care  of,  23,  386 
Deformity,  prevention  of,  in  emergency 

surgery,  523 
Delbet    arm    extension    apparatus    for 
fractures,  610 
forms  for  fractures,  624,  625 
Dental  clinic  at  Metropolitan  Life  In- 
surance Company,  63 
hygiene,  lectures  and  individual  in- 
struction to  employees  on,  63 
office,  an  essential  adjunct  to  indus- 
trial dispensary,  65 
of  medical  department,  42 
service  for  employees,  60 

economic  value  of,  60,  66 
equipment  of  offices,  63 
free  for  children  of,  63 
loan  system  for,  66 
systems  in  use  in  different  in- 
dustries, 62 
Dentists  employed  on  part  or  full  time, 

62,  65 
Department  store,  medical  attention  in, 

45 
Dichloramin-T  as  antiseptic,  515 
Dining  room,  cafeteria,  commissary  and 
locker  room,  floor  plan  of,  114 
employees',  28 
Diphtheria,  192 

Disabled  member,  functional  re-educa- 
tion of,  554 
reclamation   of,    776.     See   also    Re- 
clamation  of  disabled. 


INDEX 


829 


Disaster,  accidents  due  to,  prevention 

of,  331 
Diseased  tonsils,  489 
Diseases,  accidents  coincident  with,  707 
contagious,  in  industry,  178 
minor,  common  to  women  employees, 

422 
occupational,     prevention     of,     and 

vocational  hygiene,  222 
prevention  of,  employees'  co-opera- 
tion in,  134,  341 
venereal,  196 
Disinfectants,  gaseous,  157 

liquid,  160 
Disinfection,  156 

natural  means  of,  156 
of  cuspidors,  162 

supervision  of,  by  plant  physician, 
156 
Dispensary,  industrial,  33 
floor  plan  of,  78 
surgical,  475 
Division  of  Physical  Reconstruction  and 
Rehabilitation  of  Disabled  Soldiers, 
work  of,  467 
Doctor's  office,  33,  68 

minimum  requirements  of,  36 
Drainage  material  for  wounds,  521 

of  wounds  in  emergency  surgery,  521 
Dressing  rooms  and  lockers,  employees', 
164 
in  connection  with  examining  room, 
38 
solution  formulas,  627,  628 
Dressings  for  emergency  surgery,  536 
small,  use  of,  499 
sterile,  importance  of,  483 
surgical,  481 

schedule  for,  485 
Drinking  and  toilet  facilities  for  women 
employees,  422 
fountains,  162 
Drop,  foot,  exercise  for,  561 
Drying     oils    and    varnish    industries, 

health  hazard  regulations  for,  272 
Dust,  amounts  inhaled  in  ten  hours  iii 
dusty    industries,    table    showing, 
202 
.  as  health  hazard,  202 
character  of,  injurious  effects  of,  206 
classification  of,  203 
containing  silica  most  dangerous,  204 
from  grain  industries,  209 


Dust  from  manufacture  of  dyes,  208 

preventive    measures    against 
poisoning  from,  208 
from  production  of  textiles,  207 
from  rag  sorting  and  shredding,  209 
from  rattan  splitting  and  sorting,  209 
from  tobacco  industries,  209 
from  wood  working  industries,  209 
in  boot  and  shoe  industry,  208 
inhalation  of,  pathological  effects  of, 

204,  432 
metallic,  206 

mortality  from  occupations  in,  437 
mineral,  206 

vegetable,    from   textile    production, 
207 
Dusting  powders  in  emergency  surgery, 

537 
Dusty  occupations,  mortality  in,  437 

trades,  chief,  205 
Dyes,  dust  hazards  in  manufacture  of, 

208 
Dye-stuffs,  organic,  and  coal  tar  colors, 
production  of,  health  hazard  regula- 
tions for,  249 
Dysmenorrhea,  423 
causes  of,  426 

rectal  and  vaginal  examinations  in, 
427 

Eating  place  for  employees,  provision 

of.  111 
Economic  value  of  employees'   dental 

service,  60,  66 
Education  and  inspection  in  accident 

prevention,  339,  340 
Elbow-joint,  fractures  about,  612 
Electrical  concern,  medical  attention  in, 

46 
Electrotherapy,  551 
Elevator  shafts,  accidents  in,  321 
Emergency     surgery,     511.     See     also 

Surgery,  emergency. 
Employees  and  their  families,  medical 
and  surgical  care  for,  49 
benefit  associations,  760 

benefits  and  average  cost  to  em- 
ployees, 762 
employer's  contribution,  762 
forms  of  benefits,  763 
free  medical  care,  764 
how  should  membership  be  ob- 
tained, 761 


830 


INDEX 


Employees'  benefit  associations,  human 
side  of,  764 
in  preventive  work,  765 
three  different  forms  of  organiza- 
tion, 760 
voluntary  membership  should  be 
followed-,  761 
cafeteria  for,  113 

compensation    from    medical    view- 
point, 667 
confidence  of,  necessary  to  success  of 

medical  department,  80 
co-operation  of,  in  prevention  of  acci- 
dent and  disease,  134,  341 
dental  service,  60 

economic  value  of,  60,  66 
equipment  of  offices,  63 
loan  system  for,  66 
systems  in  use  in  different  indus- 
tries, 62 
dining  room,  28 

eating  place  for,  provision  of,  110,  111 
educated  in  food  hygiene,  110 
epidemics  among,  prevention  of,  178 
female,  examination  of,  38.     See  also 
Medical  and  physical  examination 
of  employees. 
food  in  relation  to  health  of,  109 
foot,  657 

examination  of,  659 
faulty  shoes  of,  657 
sweaty,  treatment  of,  661 
treatment  of  blisters  and  abrasions 
on,  661 
of  callosities,  661  _ 
of  corns,  660 
of  fissures,  661 
of  flat-foot,  663 
of  foot  strain,  663 
of  hallux  valgus,  662 
of  hammer-toe,  663 
of  ingrowing  nails,  662 
of  specific  conditions  in,  660 
foreign,  americanization  of,  769 
health  supervision  of,  17 

recreation  and   exercise  related 
to,  102 
home  conditions,  prevention  in,  137 
in  plant  restaurant,  medical  examina- 
tion of,  111 
medical  examination  of,  20,  355 

attitude  of  employee  toward,  368 
classes  divided  into,  357 


Employees,    medical    examination    of, 
female,  38,  416,  427 
of  new  employees,  22,  27,  86,  87, 

134,  359,  370 
of  present  working  force,  358 
problem  of  physically  unfit,  367 
reasons  in  favor  of,  357 
re-examination  in,  359,  360 
routine  procedure  for,  362 
statistics  of  examinations,  363 
steps  of  examinations,  362 
treatment  of,  391 
complete,  401 
supervision  of,  391 
types  of  eases  causing  time  loss, 

402 
what  cases  should  be  treated,  399 
new,  influence  of,  and  speeding-up,  on 
accident  rate,  351 
instruction  in  accident  prevention, 

351,  353 
medical  examination  of,  22,  27,  86, 
87,  134,  359,  370 
number  in  plant,  94 
of  plant  restaurant,  medical  examina- 
tion of.  Ill 
physical  examination  of,  20,  355 

before    entering    physical    exer- 
cises, 107 
for  prevention  of  accidents,  328, 
329 
or  mental  condition  of,   cause  of 
accidents,  328 
prevention  among,  134 

applicants  for  work,  134 
old  employees,  134 
physical  examination  of  old  and 
new,  134 
preventive  measures  rendered,  136 
recreation  for,  102 

room  for,  104 
service  department,  17 
activities  of,  19 
banking  and  loan  service,  31 
employment  service,  26 
housing  and  community  service, 

32 
insurance  service,  31 
medical  director,  head  of,  18,  19 
service,  20 

physical  examination,  20 
treatment  in,  22 
nursing  service,  24 


INDEX 


831 


Employees'  service  department,  recrea- 
tional service,  28 
restaurant  service,  27 
safety  service,  25 
sanitation  service,  26 
surgical  service,  24 
welfare  service,  30 
should  leave  work  rooms   at  lunch 

hour,  110,  111 
tuberculosis  among,  predisposing  fac- 
tors to,  432 
prevention  of,  442 
tuberculous,  429 
at  work,.  456 
care  of,  23 
decrease  of,  among  old  employees 

by  medical  examination,  368 
examination  for  discovery  of,  128 
model  garment  factory  for,  457,  458 
nurse  for,  58 
treatment  of,  444 
at  home,  449 

by  certain  organizations,  446 
by  Ford  Motor  Company,  454 
by  Jewish  Tuberculous  Associa- 
tion of  New  York  City,  456 
detection    of    disease    in    early 

stage,  445 
free,  449 
industrial  convalescence  in,  458, 

460 
periodical  medical  examinations 

for,  445 
sanatoria  for,  444,  451 
Employment  of  physically  unfit,  86,  87 

service  of  employees,  26 
Epidemics   among  employees,   preven- 
tion of,  178 
Epidemiology    in    industry,    178.     See 

also  IndiLstrial  epidemiology. 
Epilepsy,  accident  prevention  in,  329 
Estimate  of    financial  returns  due  to 

medical  department,  79 
Erersion  and  inversion  of  ankle,  561 
Examination  and  correction  of  eye  con- 
ditions, 386 
plan  for,  386 

test  for  acuity  of  vision,  387 
bacteriologic,  73 
blood,  73 
fecal,  74 

of  female  help,  38,  416,  427 
of  sputum,  73 


Examination  of  teeth,  part  of  physical 
examination,  60 
physical,  of  applicants  for  work,  22, 
27,  86,  87,  134,  359,  370 
of  employees,  20 

before    entrance    into    physical 

exercises,  107 
for  prevention  of  accidents,  328, 

329 
purpose,  21 
Examining    room    of    medical    depart- 
ment, 38 
Exanthemata,  acute,  194 
Exercise  and  recreation  as  related  to 
supervision    of    health    of    em- 
ployee, 102 
for  managerial  staff,  100 
for  foot  drop,  561 

physical,  conducted  during  working 
hours,  105 
examination    of    employee    before 
entering  into,  107 
Explosives,     manufacture     of,     health 

hazard  regulations  for,  238 
Extremity,  lower,  amputations  of,  647. 
See   also    Amputations   of   lower 
extreTuities. 
fractures  of,  616.     See  also  Frac- 
tures of  lower  extremity. 
upper,  amputations  of,  643.     See  also 
Amputations  of  upper  extremities. 
fractures  of,  606.     See  also  Frac- 
tures of  upper  extremity. 
Eye  conditions,  examination  and  cor- 
rection of,  386 
plan  for,  386 

test     for     acuity     of    vision, 
387 
ear,  nose  and  throat  work,  room  for 
in  medical  department,  42 
Eyesight,  defective,  accident  prevention 
in,  330 

Fainting,  treatment  of,  in  emergency 

surgery,  534 
Faucets  for  washing  faciUties,  163 
Fecal  examinations,  plan  used  in  large 

industry,  74 
Federal  legislation  and  administration 

in  prevention  of  occupational  disease, 

223 
Feeding  of  employees,   110,    111.     See 

also  Plant  restaurant. 


832 


INDEX 


Female  help,  examination  of,  38,  416, 

427 
Femur,  fractures  of,  616 

application  of  plaster  case  for,  622, 

623 
Hodgen  splint  in,  618,  619 
middle  of,  treatment,  621 
Ferrosilicon,  transport  of,  health  haz- 
ards in,  preventive  measures  in,  250 
Fertilizers,  manufacture  of,  health  haz- 
ard regulations  for,  242 
Field  meet,  29 

Financial  returns  due  to  medical  depart- 
ment, estimate  of,  79 
waste  due  to  employment  of  physic- 
ally unfit,  87 
Finger  amputations,  641 
Fingers  and  thumbs,  fractures  of,  614 
pulley  weight  for  exercising,  in  flexion 
and  extension,  562 
Fire,  accident  prevention  in,  331 

prevention  in  plant,  139 
First  aid,  487,  492 
in  gassing,  249 
kit,  498 

box  for,  497 

contents  of,  496,  497,  499 
directions  for,  499 
methods,  to  be  used  by  employees, 

500 
outfit  of  N.  A.  S.  O.,  507 
rules,  496 

station  in  Colorado  Fuel  and  Iron 
Co.,  493 
in  Ford  automobile  factory,  494 
in  large  plants,  25 
system  in  Bethlehem  Steel  Co.,  505 
three  systems,  493 
work  for  mine  employees,  508 
Fissures  of  skin  of  feet,  treatment  of, 

661 
Flannel  band  for  traction  in  fractures, 

611,  612 
Flat-foot,  treatment  of,  663 
Floor  plan  of  industrial  dispensary,  78. 
Food,  109 

for  women  employees,  422 

hygiene  talks  to  employees,  110 

in  plant  restaurant,  inspection  of,  by 

medical  staff,  112 
proper,  for  employees,  28 
relation  of,   to  health  of   employee, 
109 


Foot  drop,  exercise  for,  561 

employee's,   657.     See  also  Employ- 
ee's foot. 
fractures  of,  606 
strain,  treatment  of,  663 
Forearms,  fractures  of,  604,  613 
Foreign  bodies  in  wound,  removal  of  in 
emergency  surgery,  520 
employee,  americanization  of,  769 
Formaldehyd,  as  disinfectant,  157 

gas,  methods  of  evolving,  158 
Formalin,  160 

Formalin-lime  and  aluminum  sulphate 
method  of  evolving  formaldehyd  gas, 
158 
Fracture  bed  used  in  Colorado  Fuel  and 

Iron  Co.  Hospital,  621 
Fractures,  598 

about  elbow-joint,  612 

Balkan  frame  for  leg  suspension  and 

traction  in,  617,  618 
Colles',  614 

compound    infected,    treatment    by 
Carrel-Dakin  irrigation  method, 
626,  627 
treatment  of,  625 
Delbet  arm  extension  apparatus  for, 

610 
dressing  solutions  for,  formulas,  627, 

628 
early  use  of  motion  in,  601 
economic  treatment  of,  598 
emergency  treatment  of,  602 
high,  of  femur,  Jones  abduction  frame 

for,  617 
immobilization  and  transportation  of, 

599 
in  emergency  surgery,  535 
Jones'  arm  extension  splint  for,  611 
methods    of    applying    traction    to 

humerus,  611 
occupations  for  patients  in,  601 
of  carpal  bones,  614 
of  clavicle,  606 
modification  of  Sayre  dressing  for, 
607 
of  femur,  616 

application  of  plaster  case  for,  622, 

623 
Hodgen  splint  in,  618,  619 
middle  of,  treatment,  621 
of  fingers  and  thumbs,  614 
of  foot,  606 


INDEX 


833 


Fractures  of  forearm,  604,  613 

of  humerus,  Balkan  frame  for,  609 
neck  of,  treatment,  607 
triangle  wood  splint  for,  609,  610 
of  leg,  606,  616,  623 

Delbet  forms  for,  624,  625 
of  metacarpal  bones,  614 
of  ribs,  604 
of  thigh,  604 
of  upper  extremity,  606 
open  treatment  of,  629 
bad  results  of,  630 
facts  to  be  emphasized  in  use  of 

autogenous  graft,  636 
indications  for,  631,  632 
living  bone  grafts  for,  advantages 
of,  631-33 
permanent  treatment,  606 
prevention  of,  598 
severe,  Thomas'  arm  extension  splint 

for,  608 
supplies  for  emergency  treatment  of, 

603 
suspension  method  in,  advantages  of, 

620 
x-ray  in  treatment  of,  598 
Free  dental  service  for  children  of  em- 
ployees, 63 
Freezing,  treatment  of,  in  emergency 

surgery,  530 
Frost-bites,  treatment  of,  in  emergency 

surgery,  530 
Fruit  mixture  for  constipation,  prescrip- 
tion for,  426 
Functional    re-education     of    disabled 

member,  554 
Functions  of  air,  152 

factors  dependent  on,  153 

Galvanizing,  health  hazard  regulations 

in,  269 
Games   and   gymnastics  for   convales- 
cents, 564 
Gas,    acetylene,    installations,     health 
hazard  regulations  for,  247 
coke  and  tar,  production  of,  health 

hazard  regulations  for,  245 
formaldehyd,   methods  of  evolving, 
158 
Gaseous  disinfectants,  157 
Gassing,  249 

artificial  breathing  for,  249 
first  aid  in,  249 
53. 


Gassing,  symptoms,  249 
use  of  oxygen  cylinder,  249 

General  office  of  medical  department,  38 

Glue,  resin  and  turpentine,  for  fracture 
traction  bands,  612 

Goggles,    as    means   of    prevention    in 
emery  grinding,  326 

Gold  and  silver  extraction,  health  haz- 
ard regulations  for,  see  Mercury. 

Gonorrhea,  198 
cases,  care  of,  23 

Grain    industries,    health    hazards    in, 
209 

Grippe,  425 

Growth    of    industrial    health    service, 
r4sum6  of,  125 

Gymnasium  for  managerial  staff,  100 

Gymnastics   and   games  for   convales- 
cents, 564 

Hallux  valgus,  treatment  of,  662 
Hammer-toe,  treatment  of,  663 
Hand  exercise,  562 

infections,  574.     See  also  Infections, 
hand. 
Hazards,  health,   in  occupations,   201. 
See  also  Health  hazards  in  occupations. 
Headaches  and  causes  of,  422 
Health  boards  and  commissioners,  mun- 
icipal, 232 
hazards  in  occupations,  201 
arsenic  poisoning,  219 
compensation  and  insurance  in, 

272 
from  dust,  202 
from  gases  and  fumes,  210 
from  industrial  poisons,  210 
from  intoxications,  210 
industries    in    which    poisoning 

may  occur,  294-309 
lead  poisoning,  213 
legislation   covering,   in  various 

states,  229 
licensing  in,  232 
mercury  poisoning,  220 
phosphorous  poisoning,  221 
preventive  measures  in  smelting 
and  metal  handling  trades,  250 
special  preventive  measures  for 
workers,  232 
regulations    for    chemical    in- 
dustries, 237 
zinc  poisoning,  218 


834 


INDEX 


Healtli  hygiene,  industrial,  home    con- 
ditions of  employees  in,  150 
insurance,  740 

eight  states  making  investigations, 

745. 
endorsed  by  official   commissions, 

744 
for  sick  employees,  31 
group  insurance,  750 
medical    profession    deeply    inter- 
ested in,  748 
principles  of  standard  bill,  743 
rapidly  increasing  public  demand 

for,  746 
selfish   opposition   by   private   in- 
surance companies,  749 
war  conditions  emphasize  need  of, 
749 
service,  industrial,  r^sum^  of  growth 

of,  125 
supervision  in  industry,  cost  of,  94,  96 
of  employees,  17 

adjuncts  to,  banking  and  loan 
service,  31 
employment  service,  26 
housing  and  community  ser- 
vice, 32 
insurance  service,  31 
recreational  service,  28 
restaurant  service,  27 
services  of,  19 
welfare  service,  30 
food  in  relation  to,  109 
medical  service  in,  20 
nursing  service  in,  24 
purposes  of,  20 
recreation   and   exercise  related 

to,  102 
safety  service  in,  25 
sanitation  service  in,  26 
services  of,  19 
surgical  service  in,  24 
of  managerial  staff  of  industry,  98 
Heart  disease,  accident  prevention  in ,  330 
Heat  exhaustion,   treatment  in   emer- 
gency surgery,  531 
Hemorrhage  and  shock,  in  emergency 
surgery,  525,  528 
checking,  500 
pads,  use  of,  499 
prevention  of,  in  emergency  surgery, 

523 
symptoms  in,  527 


Hernia,  compensable,  690 

accidental  or  sudden  hernia,  696 
due  to  natural  causes,  698 
due  to  unnatural  causes,  700 
questions  of  traumatic  hernia  in, 

692 
true  traumatic  hernia,  694 
non-compensable,  704 
quacks,  397 
Hip,  rotation  of,  560 
History  room  of  medical  department,  39 
Hodgen  splint  in  fractures  of  femur,  61 8, 

619 
Home,  accidents  in,  338 

conditions   of   employee,   prevention 
in,  137 
Hospital,  plant,  33 
Hot  and  cold  water,  for  employees,  163, 

164 
Housing  and  community  service  of  em- 
ployees, 32 
Human  conservation  and  reclamation 
of  disabled,  776 
maintenance    department,    scope    of 
work  and  benefits  of,  81,  82 
Humerus,  fractures  of,   Balkan  frame 
for,  609 
neck  of,  treatment,  607 
triangle  wood  splint  for,  609,  610 
Humidity,  153 

Hydrochloric  acid,  salt  cake  and  soda 
industries,  health  hazard  regulations 
for,  237 
Hydrogen  peroxid  as  antiseptic,  515 
Hydrotherapy,  551 

Hygiene,  dental,  lectures  and  individual 
instruction  to  employees  on,  63 
health,  industrial,  home  conditions  of 

employees  in,  150 
industrial,  125 

and  production,  167 

business  methods  revolutionized, 

168 
commandeering  law,  173 
Committee  on  Industrial  Medi- 
cine and   Surgery,   report  of, 
174 
division  of  Sanitation  and  Safety, 

176 
effect  of  war  speed-up,  171 
efficiency  before  war,  170 
employer   and  laborer   relation- 
ships, 169 


INDEX 


835. 


Hygiene,    industrial,    and    production. 
Federal  Housing  Commission, 
173 
government   control  of   produc- 
tion, 168 
improved     railway     employees' 

conditions,  177 
reorganization  of  department  of 

labor,  172 
supervision  and  control  by  Secre- 
tary of  Treasury,  173 
U.  S.  Employees  Compensation 

Commission,  176 
work  of  Shipbuilding  Board,  176 
course    in    medical     schools,    125, 

130 
general  outline  of  problems,  141 
in  shipbuilding  yards   132 
prevention  in,  137 
problems  of,  141 

community  conditions,  150 
co-operation  between  municipal 
health  department  and  plant 
medical  staff,  149 
disinfection,  156 

doctor's  office  and  first  aid  sta- 
tions, 148 
drinking  facilities,  148,  162 
dusts,  145,  203,  432 
duty  of  plant  physician  in  regard 

to,  141 
eating  facilities,  147 
excessive  noises,  145 
fumes  and  gases,  144 
health  conditions  of  community, 
149 
hazards  present,  142 
hours  of  work,  142 
humidity,  144 
illumination,  145 
lockers  and  dressing  rooms,  147, 

164 
medical  care  of  employees,  149 
nature  and  construction  of  build- 
ings, 143 
of  industry,  141,  142 
physical  condition  of  employees, 
148 
of  plant  and  surroundings, 
143 
examinations     of     employees, 
148 
protection  against  spitting  and 
refuse,  145 


Hygiene,  industrial,  problems  of,  pro- 
visions  for    contagious  cases, 
149 
recreational  facilities,  148 
rest  rooms,  148 
specific,  151 

surroundings  of  plant,  144 
temperature,  144 
toilet  facilities,  147,  164 
vacations  and  recreation,   149 
ventilation,  144,  151 
wages,  143 

washing  facilities,  147,  163 
personal,    in   handling    of    poisonous 

materials,  234 
vocational,  and   prevention  of  occu- 
pational diseases,  222 
Hygrodeik,  Taylor,  153 
Hypochlorite   disinfection   of   drinking 
water,  162 

Illuminated  signs  in  spirit  of  preven- 
tion education,  343 
Immobilization  of  fractures  and  sprains 

in  emergency  surgery,  535 
Increase  in  number  of  employees  com- 
ing to  doctor,  80,  83 
Individual  instruction  and  lectures  to 

employees  on  dental  hygiene,  63 
Industrial  accidents,  division  of,  319 
army,  health  of,  plan  for  supervision 

of,  465 
dispensary,  33 

floor  plan  of,  78 
epidemiology,  178 

early  isolation  and  treatment,  191 
education  and  individual  preven- 
tion, 192 
epidemic    of    1915-16,     complica- 
tions in,  186 
course  of  disease  in,  186 
etiology  of,  181 
pneumonia  in,  186 
symptoms,  184 
treatment,  187 
active,  189 
preventive,  188 
results,  189 
in  acute  exanthemata,  194 
in  colds,  178 
in  diphtheria,  192 
in  influenza,  180 
in  lumbago,  179 
in  pneumonia,  180 


836 


INDEX 


Industrial    epidemiology  in  small-pox, 
195 

in  tonsillitis,  180 

in  torticollis,  179 

in  typhoid  fever,  195 

in  venereal  diseases,  196 

reinforcing  sanitation  methods  in, 
192 

searching  out  cases,  191 
health  service  of  employees,  17 

r6sum6  of  growth  of,  125 
hygiene.     See  H>ygiene,  industrial. 
medical  office  serving  several  indus- 
tries, 48 
medicine,  355 

and  surgery,  practical  system  of, 
detailed  outline  of,  in  large  in- 
dustry, 67 
nurse,  conserves  physicians'  time,  57 

daily  routine  of,  53 

at  plant  and  in  homes,  54 

for  tuberculous  cases,  58 

number  employed  in  plant,  93 

qualifications  of,  51,  58 

report  of  request  to  call,  124 

responsibilities  of,  52 

Nurses'  Club  of  Chicago,  69 
nursing,  51 
plant,  accident  prevention  in,  138 

fire  prevention  in,  139 

prevention  in  relation  to  physical 
conditions  of,  137 
poisons,  arsenic,  219 

classification,  211 

definition,  210 

important  role  in,  211 

laws  requiring  reporting  of  cases  of, 
212 

lead,  213 

list  of,  274-293 

mercury,  220 

phosphorous,  221 

zinc,  218 
sanitation,  125.     See  also  Sanitation. 
surgeon's    place   in    americanization 

of  foreign  employee,  769 
surgery,  475.     See  also  Surgery,  in- 
dustrial. 
Industries,  activities  of,  prevention  as 

related  to,  139 
in  which  poisoning  may  occur,  294- 

309 
nurse  in,  51 


Industries,   prevalence  of   tuberculosis 
in,  431 
preventive  medicine  and  surgery  in, 

133 
respiratory  infections  in,  178 
women  in,  405.     See  also  Women  in 
industry. 
Inefficiency  among  employees,  30 
Infections  following  injuries,  reduction 
of,  by  medical  department,  85 
from  minor  accidents,  prevention  of, 

332 
hand,  574 

active  treatment,  581 
early  hospital  treatment  for,  584 
economic    value    of    diagnosis    of 
location  of  pus  and  surgical  in- 
terference in,  590 
prevention  of,  577 
iodin  in,  578 

removal  of  predisposing  causes  in 
employees,  579 
r61e  of  tonsillitis  in,  580 
in  emergency  surgery,  prevention  of, 
513 
closure  of  wounds  in,  522 
drainage  of  wounds  in,  521 
iodin  in,  514 
prevention  of,  500 
respiratory,  in  industry,  178 
teeth  a  source  of,  61 
Influence  of  new  employees  and  speed- 
ing-up, on  accident  rate,  351 
Influenza,  180 
Information   record   of   applicants   for 

work,  117 
Ingrowing  nails,  treatment  of,  662 
Inhalation  of  dust,  pathological  effects 

of,  204,  432 
Injured,  mental  idleness  drawback  to, 
547 
psychotherapeutic  treatment  of,  544 
subsequent  or  permanent  treatment 
of,  543 
Inspection  and  education  in  accident 
prevention,  339,  340 
sanitary,  of  plant,  26 

restaurant  by  medical  staff,  111, 
112 
Inspectors  of  safety  methods,  341 
Insurance,  667 

and  compensation,  272 

health,  740.   See  also  Health  insurance. 


INDEX 


837 


Insurance  service  of  employees,  31 
Inversion  and  eversion  of  ankle,  561 
lodin  and  applicators,  rack  for,  497 
immediate  use  of,  first  aid  procedure, 

503 
in  emergency  surgery,  514 
strength  employed,  514 
use  of,  499 

preventive  measure  in  minor  acci- 
dents, 332 
Iron  works,  health  hazards  in,  prevent- 
ive measures,  in,  250 

Jaw,  phossy,  221 

Jewish  Tuberculous  Association  of  New 

York  City,  456 
Joint,  re-education  of,  557 
Jones'  abduction  frame  for  high  frac- 
tures of  femur,  617 

arm  extension  splint,  611 

cock-up  wrist  splint,  614 

Knee,  rotation  of,  560 

Labor  turn-over,  estimates  of  cost  of,  88 
reduction  of,   by  medical  depart- 
ment, 84,  85 
Laboratory  in  connection  with  doctor's 
office,  73 
in  hospital,  40 

in  medical  department,  39,  40 
Lay  assistants,  number  needed  in  med- 
ical department,  93 
Lead  colic,  215 

compounds,  danger  of,  216 
health  hazards  of  workers  in,  preven- 
tive measures  for,  251 
industries  in  which  used,  health  regu- 
lations of  European  governments 
for,  252,  254 
paralysis,  216 
poisoning,  213 
colic  in,  215 

dangerous  trades  found  in,  216 
diagnosis  of,  Gower's  three  postu- 
lates in,  214 
examination  for  early  diagnosis  of, 

214 
paralysis  in,  216 
symptoms,  213 
smelting,  advice  to  employees  in,  264 
to  employers  in,  264 


Lead  smelting,  duties  of  occui)icr  in, 
260 
of  persons  employed  in,  263 
general  regulations  for,  256 
health  hazards  in,  German  Imperial 
Regulations  for,  256 
preventive  measures  in,  255 
regulations  for  clothing,   overalls, 
and  lavatory  accommodations 
in,  258 
for  employment  of  workers   in, 
258 
special  regulations  for   distillation 
of  zinc  skimmings,  257 
for  lead  colors  preparation,  257 
trades,  dangerous,  216 
white,  production  of,  health  hazard 

regulations  in,  265 
works,  poisoning  in,  217 
Lectures  and  individual  instruction  to 

employees  on  dental  hygiene,  63 
Leg,  fractures  of,  606,  616,  623 
Licensing,  232 
Lime,  chlorinated  as  disinfectant,  161 

milk  of,  as  disinfectant,  161 
Liquid  disinfectants,  160 
Liquor  cresolis  compositus,  160 
Loan  and  banking  service  of  employeeSj 
31 
system  for  dental  care  of  employees, 
66 
Location   of   medical  department,   33- 

37 
Locker  and  dressing  rooms,  164 

room,    cafeteria,    dining    room    and 
commissary,  floor  plan  of,  114 
Lockjaw.     See  Tetany^. 
Loss,  financial,  due  to  employment  of 

physically  unfit,  87 
Lumbago,  179 

Lunch  of  employees,  deficient  in  calo- 
ries, 110 
where  eaten,  110 

Machinery,  broken,  cause  of  accidents, 
323 

safety  appliances  on,  324 
Major  accidents,   preventive  measures 

in,  320 
Malingering,  732 

absolute  faking  in,  735 

medicolegal  aspects  of,  732 

true,  732 


838 


INDEX 


Managerial  staff,  diplomacy  in  medical 
treatment  of,  99 
periodical  medical  examination  of, 

99 
recreation  and  exercise  for,  100 
sets  example  for  employees,  99 
supervision  of  health  of,  98 
Manures,    artificial,    manufacture    of, 

health  hazard  regulations  for,  242 
Marsee  tin  finger  splint,  615 
Massage,  551 
Mechanotherapy,  556 
Medical  and  surgical  care  for  employees 
and  their  families,  49 
supervision  of  employees,  cost  of, 
84 
department,  33 

and  service  room  plan,  34 
benefits  and  profits  of,  79 
city  health  department  and,  close 

cooperation  between,  1 13 
cost  of,  90 

caliber   of  physicians  employed, 

90 
number  of  employees,  94 

of   hours    physicians    are    en- 
gaged, 90 
of  industrial  nurses  employed. 

93 
of  lay  assistants  employed,  93 
of  physicians  needed,  93 
on  staff,  92 
total,  94 
dental  office  of,  42 
estimate  of  financial  returns  due 

to,  79 
examining  room,  38 
food  of  employees  a  responsibility 

of,  109,  110 
general  office,  38 
history  room,  39 
laboratory  of,  39 
location  of,  33-37 
minimum  requirements  of,  36 
offices  of,  37 
prevention  of  spread  of  epidemic 

diseases  by,  178 
preventive  work  of,  133 
private     office     of     physician     in 

charge,  39 
records,  116 

doctor's  office  pass,  118 
record,  116,  119 


Medical     department      records,      em- 
ployee's pass  home,  120 
filing  of,  116 
information,    of    applicants    for 

work,  ]17 
report  of  accident,  121,  122,  123 
request  for  nurse's  call,  124 
return  to  work  pass,  120 

rest  rooms  of,  42,  582 

rooms  for  eye,  ear,  nose  and  throat 
work,  42 

sanitary  inspection  of   plant  res- 
taurant, by.  111,  112 

sources  of  profit  from,  84 

sterilizing  room  of,  41 

success  of,  confidence  of  employees 
necessary  to,  80 

supervision    of    physical    exercises 
by,  107 
of  plant  restaurant  by,  111 

surgical  room  of,  40 

toilet  facilities  of,  42 

waiting  room,  38 

x-ray  laboratory  of,  41 
director,  44 

as  head  of  employees  service  de- 
partment, 18,  19 
examination  of  applicants  for  work, 
22,  27,  86,  87,  134,  359,  370 
do  they  object  to  examinations, 

381 
fitting  disabled  to  jobs,  382 
percentage  of  rejects,  384 
reasons  for  examination,  372 
rejection  standards,  377 
should  diseased  conditions  be  ex- 
plained, 380 
what  becomes  of  rejects,  383 
when  to  examine,  371 

of  employees,  355 

attitude  of  employee  toward,  368 
classes  divided  into,  357 
female,  38,  416,  427 
in  plant  restaurant,   111 
new,  359 

of  lead  process,  262,  263 
present  working  force,  358 
problem  of  physically  unfit,  367 
reasons  in  favor  of,  357 
re-examination  of,  359,  360 
routine  procedure  for,  362 
statistics  of  examinations,  363 
steps  of  examination,  362 


INDEX 


839 


Medical    examination,    periodical,    for 
managerial  staff,  99 
office,  industrial,  serving  several  in- 
dustries, 48 
service  of  employees,  20 
staff,  43 

duties  and  size  of,  43-50 
treatment  of  employees,  22,  391 
complete,  401 
supervision  of,  391 
types  of  cases  causing  time  loss, 

402 
what  cases  should  be    treated, 
399 
Medicine,  industrial,  355 

preventive,  in  industry,  133 
Medicolegal  phases,  667 
Men's  rest  room,  582 
Mental  idleness,  drawback  to  injured. 

547 
Mercurialism,  220 

Mercury,  bichlorid  of,  as  disinfectant, 
161 
health  hazards  in  use  of,  regulations 

for,  269 
poisoning,  220 
symptoms,  220 
Metacarpal  bones,  fractures  of,  614 
Metal  handling   trades   and   smelting, 
preventive  measures  in,  250 
pickling,    health   hazard   regulations 

in,  269 
shakes,  218 
Metallic  dust,  206 

mortality    from     occupations     in. 
437 
Milk  of  lime,  161 
Mineral  dust,  206 

Minor  accidents,  preventive  measures 
in,  331 
diseases    common    to    women    em- 
ployees, 422 
Misfits  among  employees,  30 
Model  cafeteria  for  employees,  113 

office  room,  146 
Mortality  in  dusty  occupations,  437 
Motion  picture  shows  for  employees, 

105 
Mouths,  unclean,  prevalence  of,  61 
Municipal  health  boards  and  commis- 
sioners, 232 
Munition  factory  in  England,  170 
Mutual  benefit  associations,  31 


Nails,  ingrowing,  treatment  of,  662 
National    Safety    Council,    history  of, 

310 
Neck,  stiff,  179 

Nervousness  among  employees,  30 
Neuroses,    traumatic,    medicolegal    as- 
pects  of,    721.     See  also    Traumatic 
neuroses. 
Nitric  acid  and  explosives,  health  haz- 
ard regulations  for,  238 
Nurse,  industrial,  51 

Club  of  Chicago  for,  59 
conserves  physician's  time,  57 
daily  routine  of,  53 

at  plant  and  in  homes,  54 
for  tuberculous  cases,  58 
number  employed,  93 
qualifications  of,  51,  58 
report  of  request  to  call,  124 
responsibilities  of,  52 
surgical,  478 
Nursing  service  of  employees,  24 


Occupational  diseases,  prevention  of 
and  vocational  hygiene,  222 
compensation  and  insurance  in, 

272 
measures  ia  smelting  and  metal 

handling  trades,  250 
special  measures  for  workers,  232 
regulations    for    chemical    in- 
dustries, 237 
three    legislative    measures    for, 
225 
hazards  in  tuberculosis,  437 
therapy,  549 
Occupations,  dusty,  mortality  in,  437, 
438 
health    hazards    in,    201.     See    also 

Health  hazards  in  occupations. 
ward,  for  convalescent  soldiers,  780 
Office,  doctor's,  33 

of  medical  department,  37 
surgical,  479 

equipment  of,  480 
Ointments    in     emergency      surgery, 

538 
Orchitis,  traumatic,  medicolegal  aspects 

of,  738 
Organization,  successful  plan  of,  in  one 

industry,  18 
Outdoor  athletics  for  employees,  107 


840 


INDEX 


Painters'  trade,  health  hazard  regula- 
tions in,  265 
Painting  and  allied  trades,  lead  poison- 
ing in,  217 
Paraffin  treatment  of  burns,  537-540 
Paralysis  in  lead  poisoning,  216 
Patent  medicine  quackery,  395,  398 
Pathological  effects  of  inhalation  of  dust, 

204,  432 
Pay  envelopes,  prevention  propaganda 

on,  342,  343 
Permanent  or  subsequent  treatment  of 

injuries,  542 
Permanganate-formalin  method  of 

evolving  formaldehyd  gas,  158 
Personal  hygiene  in  handling  of  poison- 
ous materials,  234 
Petroleum   in   industry,  health  hazard 

regulations  for,  244 
Phalanx,  terminal,  crushes  of,  616 
Phosphorus  in  industry,  health  hazard 
regulations  for,  245 
poisoning,  221 
Phossy  jaw,  221 

Physical  examination  of  applicants  for 
work,  22,  27,  86,  87,  134,  359,  370 
of  employees,  20 

before  entrance  into  physical  ex- 
ercises, 107 
for  prevention  of  accidents,  328, 

329 
purpose,  21 
exercises  conducted  during  working 

hours,  105 
or  mental  condition  of  employee,  acci- 
dents due  to,  328 
selection     of    employees    for    work, 
source  of  profit  from  medical  de- 
partment, 86 
Physically  unfit,  employment  of,  86,  87, 

374-377 
Physicians,  number  needed  in  medical 
department,  93 
of  hours  employed,  92 
on  staff,  92 
Physiotherapy,  551 

Placards  for  spread  of  spirit  of  preven- 
tion, 336,  337 
Plan  of  sleeping  shack  for  six  patients, 

453 
Plant  hospital,  33 

industrial,  accident  prevention  in,  138 
fire  prevention  in,  139 


Plant,  industrial,  prevention  as  related 
to  physical  conditions  of,  137 
physician,  duty  in  regard  to  hygiene 
of  plant,  141 
in    detection    and    prevention    of 

health  hazards,  201 
should  inspect  drinking  fountains, 

162 
supervision    of    plant    disinfection 
by,  156 
restaurant,  110 

medical  examination  of  employees 

of.  111 
sanitary  inspection  of  by  medical 

staff.  111,  112 
supervision  of,  by  medical  depart- 
ment, 111 
surgeon  leader  in  spirit  of  prevention, 

339,  349 
walls,  finish  of,  164 
Plaster  bouillon  for  casts,  method  of 

preparing,  622 
Playgrounds,  105 
Plumbism,  213.     See  also  Lead  poisorir- 

ing. 
Pneumonia,  180 
Poisoning,  arsenic,  219 

in  American  trades,  220 
in  English  trades,  219 
industries  in  which  may  occur,  294- 

309 
lead,  213 
colic  in,  215 

dangerous  trades  found  in,  216 
diagnosis  of,  Gowers's  three  postu- 
lates in,  214 
examination  for  early  diagnosis  of, 

214 
paralysis  in,  216 
symptoms,  213 
mercury,  220 

symptoms,  220 
phosphorous,  221 
trinitrotoluene,  238 
causation,  239 
prevention,  240 
symptoms,  240 
treatment,  241 
zinc,  218 
Poisons,  industrial,  arsenic,  219 
classification,  211 
definition,  210 


INDEX 


841 


Poisons,   industrial  important  role   in, 
211 
laws  requiring  reporting  of  cases  of, 

212 
lead,  213 
list  of,  274-293 
mercury,  220 
phosphorous,  221 
zinc,  218 
Pott's  fracture,  606 

Power  gas  works,  health  hazard  regula- 
tions for,  245 
Pox,  198 

Practical  system  of  industrial  medicine 
and  surgery,  detailed  outline  of,  in 
large  industry,  67 
Predisposing    factors    to    tuberculosis 

among  employees,  432 
Prescription  for  fruit  mixture  for  con- 
stipation, 426 
Prevalence  of  unclean  mouths  and  de- 
cayed teeth,  61 
Prevention,  133 
among  employees,  134. 

applicants  for  work,  134 
old  employees,  134 
physical  examination  of  old  and 
new,  134 
as  related  to  activities  of  industry, 
139 
to  physical  conditions  of  plant,  137 
in  employees  home  conditions,  137 
in  industrial  hygiene,  137 
in  relationship  between  employee  and 
fellow  employees,  136 
and  his  work,  135 
m.easures  rendered  employee,  136 
of  accidents,  318,  319,  486 
and  recurrences  of,  25 
depends  upon  inspection  and  edu- 
cation, 339 
due  to  disaster,  331 
due  to  physical  or  mental  condition 

in  employee,  328 
employees'    co-operation   in,    134, 

341 
in  plant,  138 

inspectors  of  safety  methods  in,  341 
major,  320 
minor,  331 

safety  appliances  attached  to  em- 
ployee, 326 
on  machinery,  324 


Prevention  of  complications  when  ac- 
cidents occur,  487 
of   disease,    employees'    co-oporation 

in,  134,  341 
of  fire,  in  industrial  plant,  139 
of  infection  in  hand  injuries,  577 
of   occupational   diseases   and   voca- 
tional hygiene,  222 
compensation  and  insurance  in, 

272 
measures  in  smelting  and  metal 

handling  trades,  250 
special  measures  for  workers,  232 
regulations  for  chemical  indus- 
tries, 237 
three    legislative    measures   for, 
225 
of  permanent  loss  of  function  of  in- 
jured part,  488 
of  premature  breakdowns,  488 
of   spread   of   epidemic    diseases   by 

medical  staff,  178 
of  tuberculosis  among  employees,  442 
of  undue  loss  of  time  from  work,  488 
propaganda,  135 

on  pay  envelopes,  342,  343 
spirit  of,  335 

inspection  and  education  in,  339, 

340 
plant  surgeon  leader  ia,  339,  349 
Preventive  legislation,  lack  of,  127 
measures  for  workers,  special,  232 
in   smelting    and    metal    handling 
trades,  250 
medicine    and    surgery    in  industrj^ 

133 
surgery,  475,  485 
Printing  trades,  health  hazard  regula- 
tions in,  267 
lead  poisoning  in,  218 
Private  office  for  physician  in  charge  of 

medical  department,  39 
Privies,  specifications  for,  165 
Prizes,  in  accident  prevention  methods, 

341 
Problems  of  industrial  hygiene,  141 
Production  and  industrial  hygiene,  167. 
See  also  Hygiene,  industrial  and  'pro- 
duction. 
Profits  and  benefits  of  medical  depart- 
ment, 79 
sources  of,  from  medical  department, 
84 


842 


INDEX 


Propaganda,  anti-accident,  339 

prevention,  135 
Protractors    for    measuring    angles    of 
movement  in  shoulder,  elbows,  wrist, 
knee  and  ankle,  557 
Provision  of  individual  wash  basin  or 
trough,  163 
of  washing  faucets  in  toilet  rooms,  165 
Psychotherapeutic  treatment  of  injured, 

544 
Psychrometer,  SUng,  153 
Pulley  weights  for  exercising  fingers  in 
flexion  and  extension,  562 
triplicate,  556 

Quackery,  in  hernia  treatment,  397 

in  surgical  appliances,  397 

in  venereal  diseases,  395 

patent  medicine,  395,  398 
Qualifications  of  industrial  nurse,  51,  58 
Quickhme  as  disinfectant,  161 

Rags,    sorting   and   shredding,    health 

hazards  in,  209 
Rattan,  splitting  and  sorting,  dust  haz- 
ards in,  209 
Reclamation  of  disabled,  776 

physical   reconstruction   in    army, 
778 
in  industries,  785 
size  of  problem,  787 
solution  of  problem,  796 
usual  method  in  industry,  786 
Reconstruction,  769 
Records,  medical  department,  116 
doctor's  office  pass,  118 

record,  116,  119 
employee's  pass  home,  120 
filing  of,  116 
information,    for   applicants   for 

work,  117 
report  of  accident,  121,  122,  123 
request  for  nurse's  call,  124 
return  to  work  pass,  120 
Ree»eation  and  exercise  as  related  to 
supervision  of  health  of  employ- 
ees, 102 
for  managerial  staff,  100 
for  employees,  102 
room  for  employees,  104,  105 
service  of  employees,  28 
Re-education,  functional,  554 
of  injured  joint,  557 


Report  of  Committee  on  Factories,  36 
Resin  and  turpentine  glue  for  fracture 

traction  bands,  612 
Respiratory    infections     in     industry, 

178 
Responsibility    of    industrial    nursing 

service,  52 
Rest,  essential  preventive  measure,  519 
periods  for  women  employees,  420 
room  for  men  employees,  582 
for  women  employees,  419,  420 
of  medical  department,  42 
Restaurant,  plant,  110 

medical  examination  of  employees 

in.  111 
sanitary  inspection  of,  by  medical 

staff,  111,  112 
supervision  of,  by  medical  depart- 
ment, 111 
service  of  employees,  27 
Resume  of  growth  of  industrial  health 

service,  125 
Resuscitation,  use  of,  501 

in  emergency  surgery,  530 
Ribs,  fracture  of,  604 
Rotation,    flexion    and    extension    and 
lateral  movements  of  wrist,  559 
of  hip,  560 
of  knee,  560 
Routine,  daily,  of  industrial  nurse,  53 
at  plant  and  in  homes,  54 

Safety  appliances  attached  to  em- 
ployee, 326 
on  machinery,  324 
committees  among  employees,  341 
engineer,  25 
first,  310,  341 

methods,  inspectors  of,  341 
organizations,  339,  340 
service  of  employees,  25 
Salt  cake,  hydrochloric  acid  and  soda 
industries,  health  hazard  regulations 
for,  237 
Sanatoria  for  treatment  of  tuberculous 

employees,  444 
Sanitary  inspections  of  plant,  26 

of  restaurant  by  medical  staff,  111, 
112 
Sanitation,  industrial,  125 

movements,  employees'  co-operation 

in,  134 
service  of  employees,  26 


INDEX 


843 


Sanitation,  state  labor  laws  in  relation 

to,  resume  of,  125,  126 
Schafer  method  for  artificial  breathing, 

249 
Sears  shack,  Edwards  Sanatorium,  453 
Service  departments  of  employees,  17 
banking  and  loan,  31 
dental,  60 
employment,  26 
housing  and  community,  32 
insurance,  31 
medical,  20 
nursing,  24 
recreational,  28 
restaurant,  27 
safety,  25 
sanitation,  26 
surgical,  24 
welfare,  30 
Sheet  or  spray  method  of  evolving  f  orm- 

aldehyd  gas,  159 
Shipbuilding  yards,  industrial  hygiene 

in,  132 
Shock  and  hemorrhage  in  emergency 
surgery,  525,  528 
combating,  500 
in  emergency  surgery,  528 

treatment,  526,  528 
symptoms  of,  527 
Shoddy,  production  of,  health  hazards 

in,  209 
Showers  for  employees,  163 
Shredding,  rag,  health  hazards  in,  209 
Silver  and  gold  extraction,  health  haz- 
ard regulations  for,  see  Mercury. 
Sitting  positions  for  women  employees, 

420 
Sling  psychrometer,  153 
Small-pox,  195 
Smelter  shakes,  218 
Smelting   and   metal  handling   trades, 
preventive  measures  in,  250 
lead,  255.     See  also  Lead  smelting. 
Soap  holders  for  employees'  toilets,  163 
Soda,  salt  cake  and  hydrochloric  acid 
industries,  health  hazard  regulations 
for,  237 
Soldiers,   disabled,  reclaiming  of,   467, 
468 
War  Risk  Insurance  for,  468 
tuberculous,  provision  for,  469 

reclaiming   of,   from  military  and 
industrial  armies,  461 


Specifications  for  urinals,  165 
Spocding-up  and  new  employees,  influ- 
ence of,  on  accident  rate,  351 
Spirit  of  prevention,  335 
Splint,  Hodgen,  in  fractures  of  femur, 
618,  619 
Jones'  arm  extension,  611 

cock-up  wrist,  614 
Marsee  tin,  for  finger,  615 
necessary  in  emergency  surgery,  603 
Thomas,  603 

for  suspension  and  traction,  620 
method  of  applying,  604,  605,  606 
wood  triangle,  used  in  French  army 
hospitals,  610 
Sprains,    treatment    of,    in    emergency 

surgery,  535 
Spray    or    sheet    method    of    evolving 

formaldehyd  gas,  159 
Sputum  examination,  plan  used  in  large 

industry,  73 
Staff,  medical,  43 

surgical,  plans  for,  476 
State  labor  laws  in  relation  to  sanita- 
tion, resume  of,  125,  126 
Sterile  dressings,  importance  of,  483 
Sterilizing  room,  481 

of  medical  department,  41 
Stiff  neck,  179 

Stomach  analyses,  plan  used  in  large 
industry,  74 
troubles,  425 
Stove  factory,  medical  attention  in,  44 
Strained      backs      coincidental     with 

disease,  715 
Stretcher  bed,  use  of  in  army  hospital, 
600 
table,  599 
Subsequent  or  permanent  treatment  of 

injuries,  542 
Successful  plan  of  organization  in  one 

industry,  18 
Sulphur  as  disinfectant,  157 

dioxid,  159 
Sulphuric  acid  industry,  health  hazard 

regulations  for,  237 
Sunstroke,  treatment  of,  in  emergency 

surgery,  531 
Supervision  of  health  of  employees,  17 
recreation   and   exercise   related 
to,  102 
of  managerial  staff,  98 
Supplies,  surgical,  481 


844 


INDEX 


Surgeon,  industrial,  duties  of,  in  rela- 
tionship to  compensation,  682 
place  in  americanization  of  foreign 
employee,  769 
Surgery,  accident,  sources  of,  484 
emergency,  611 

accidents  and  wounds  in,  512,  513 
cleansing  wound  in,  520 
closure  of  wounds  in,  522,  532 
combat    immediate    complications 

in,  523 
combating  shock  in,  523 
drainage  of  wounds  in,  521 
dressings  for,  536 
fainting  in,  treatment,  534 
frost-bites  in,  treatment,  530 
heat  exhaustion  in,  treatment,  531 
hemorrhage  and  shock  in,  525,  528 
immobilization  of  fractures  in,  535 
impending  death  in,  523 
infections  in,  513 
iodin  as  antiseptic  in,  514 
other  antiseptics  used  in,  515 
prevention  of  comphcations  in,  513 
of  deformity  in,  523 
of  hemorrhage  in,  523 
of  tetanus  in,  522 
removal    of    foreign    bodies    from 

wound,  520 
rest  in  prevention  in,  519 
sequence  of  treatment  in,  513 
shock  and  hemorrhage  in,  525,  528 
sprains  in,  treatment,  535 
sunstroke  in,  treatment,  531 
temporary  and  permanent  relief  in, 
532 
industrial,  475 
a;-ray  in,  568 
preventive,    in    industry,  .  133,   475, 
485 
Surgical  and  medical  care  for  employees 
and  their  families,  49 
supervision  of  employees,  cost  of, 
84 
dispensary,  475 
dressing  room  for  men,  478 

for  women,  480 
dressings,  schedule  for,  485 

suppUes  and  bandages,  481 
nurse,  478 
office,  479 

equipment  of,  480 
room  of  medical  department,  40 


Surgical  service  of  employees,  24 

staff,  plans  for,  476 
Sweaty  feet,  treatment  of,  661 
Syphilis,  198 

cerebrospinal,  accident  prevention  in, 
330 
Syphilitic  cases,  care  of,  23 

Table,  bed,  suitable  for  games  or  bed- 
side occupations,  555 
stretcher,  599 
Tailors  and  garment  workers,  tubercu- 
losis among,  208 
Tar,  coke  and  gas,  production  of,  health 
hazard  regulations  for,  245 
products,    from    distillation;    health 
hazard  regulations  for,  248 
Taylor  hygrodeik,  153 
Teeth,  diseased,  prevalence  of,  61 
examination  of,  part  of  physical  ex- 
amination, 60 
Temperature,  153 

Tent  in  rear  of  fiat  building  for  tubercu- 
lous employee,  450 
Tetanus,  prevention  of,  in  emergency 

surgery,  522 
Thigh,  fractures  of,  604 
Thomas  arm  extension  splint  for  severe 
fractures,  608 
splint,  603 

for  suspension  and  traction,  620 
method    of    applying,     604,    605, 
606 
Tin  strips  for  protection  of  injured  fin- 
ger, 483 
Tobacco  industries,  health  hazards  in, 

209,  210 
Toilet  and  drinking  facilities  for  women 
employees,  422 
facilities  of  medical  department,  42 
Toilets  in  plant,  164 

number  of  installations,  164 
provision  of  washing  faucets  in,  165 
specifications  for  closets  in,  165 

for  urinals  in,  165 
urinals  in,  165 
Tonsillitis,  180,  425 

role  in  hand  infections,  580 
Tonsils,  diseased,  489 
Tooth-brush  drill  conducted  by  com- 
pany nurse,  62 
Torticollis,  179 
Trades,  dusty,  chief,  205 


INDEX 


845 


Transfusion,  blood,  in  shock  in  emer- 
gency surgery,  527,  530 
Traumatic    apoplexy,    medicolegal    as- 
pects of,  736 

appendicitis,  medicolegal  aspects  of, 
736 

displacements  of  uterus,  medicolegal 
aspects  of,  738 

neuroses,  age  and  sex  in,  726 
desire  for  gain  in,  724 
exciting  cause  of,  726 
fear  and  suggestion  in,  725 
medicolegal  aspects  of,  721 
moral  instability  in,  722 
neurasthenia    and   hysteria   recog- 
nized types  of,  726 
psychic  impressions  in,  726 
race  influence  in,  726 
treatment  of,  727 

orchitis,  medicolegal  aspects  of,  738 
Traumatisms  and  tuberculosis,  relation- 
ship between,  435,  436 

with  medicolegal  aspects,  719 
Treatment  of    conditions   directly  the 
result  of  occupations,  22 

of  home  accidents,  22 
Trinitrotoluene  poisoning,  238 
causation,  239 
prevention,  240 
symptoms,  240 
treatment,  241 
Triplicate  pulley  weight  for  mechano- 
therapy, 556 
Tuberculosis,  429 

and    traumatisms,    relationship    be- 
tween, 435,  436 

cases,  care  of,  23 

decrease  in,  among  old  employees,  by 
medical  examinations,  368 

occupational  hazards  in,  437 

predisposing  factors  to,  among  em- 
ployees, 432 

prevalence  of,  in  industry,  431 

prevention  among  employees,  442 

problem  in  army,  467 

pulmonary,   among  tailors  and  gar- 
ment workers,  208 
Tuberculous  employees,  429 
at  work,  456 

examination  for  discovery  of,   128 
model  garment  factory  for  457,  458 
nurse  for,  58 
treatment  of,  444 


Tuberculous  employees,    treatment  of, 
at  home,  449 
by  certain  organizations,  446 
by  Ford  Motor  Company,  454 
by  Jewish  Tuberculous  Associa- 
tion of  New  York  City,  456 
detection    of    disease    in    early 

stage,  445 
free,  449 
industrial  convalescence  in,  458, 

460 
periodical  medical  examinations 

for,  445 
sanatoria  for,  444,  451 
from  military  and  industrial  armies, 
plan    for    physical    reconstruction 
and  rehabilitation  of,  469-473 
industrial  soldiers,  problems  in  care 

of,  466 
soldier,  provision  for,  469 

reclaiming  of,  from  military  and 
industrial  armies,  461 
Turpentine  and  resin  glue  for  fracture 
traction  bands,  612 
as  antiseptic,  515 
Typhoid  fever,  178,  195 
from  unsanitary  toilets,  135 
inoculations,  49 

Unfit,  physically,  employment  of,  86, 
87,  374-377 

Unjust  compensation  and  litigation,  re- 
duction of,  by  medical  department, 
85,  86 

Upper  extremity,  fractures  of,  606 

Urinals,  number  of,  in  plant,  165 
specifications  for,  165 

Urinalyses,  plan  used  in  large  industry, 
72 

Uterus,  traumatic  displacements  of, 
medicolegal  aspects  of,  738 

Vaccinations,  49 

Valmora  Industrial  Sanatorium,  455 

Varnishes    and    drying    oil    industries, 

health  hazard  regulations  for,  272 
Vegetable  dust,  hazards  of,  in  textUe 

production,  207 
Venereal  diseases,  196 

beware  of  advertising  specialists, 

198  J 
prevention,  198 

propaganda,  197,  198 


846 


INDEX 


Venereal  diseases,  what  to  do  in,  198 

quack,  395 
Ventilation,  adequate,  155 

principles  of,  151,  152 
Vicious  circle,  30 
Vision,  defective,  care  of,  23 
Vocational  hygiene  and  prevention  of 

occupational  diseases,  222 

Waiting  room  of  medical  department, 

38 
Wall  paper  production,  health  hazards 

in,  209 
Walls  of  plant,  finish  of,  164 
Ward     occupations     for     convalescent 

soldiers,  780 
Washing  facihties,  for  employees,  163 
clothes  hooks,  163 
hot  and  cold  water,  164 
location  of  supply  pipes,  164 
number  of  faucets,  163 
provision     of    individual    wash 

basins,  163 
showers,  163 
soap  holders,  163 
spacing  of  fixtures,  163 
Waste,  financial,  due  to  employment  of 

physically  unfit,  87 
Welfare  service  of  employees,  30 
Wet  and  dry  bulb  for  temperature  of 

plant,  153 
White  lead  production,   health  hazard 

regulations  in,  265 
Whitewash  as  disinfectant,  161 
Women  in  industry,  405 

choosing  occupations  for,  413 

clothing  of,  421 

drinking   and   toilet  facilities   for, 

422 
food  for,  422 

medical  supervision  for,  411-413 
minor  diseases  common  to,  422 
colds,  423 

constipation,  423,  425 
dysmenorrhea,  423,  426 
grippe,  425 
headaches,  422 
stomach  trouble,  425 
tonsillitis,  425 
physical  examination  of,  414 
problems  of,  411 


Women  in  industry,  question  of  hours 
of  labor  for,  408 
recommendations    by    Committee 
on  Standards  of  Working  Con- 
ditions, 409 
rest  rooms  for,  419 
routine    examination    of    girl    em- 
ployees, 416 
sitting  positions  and  rest  periods 

for,  420 
which  girl  employees  are  examined, 
419 
Wood  working  industries,  dust  from,  209 
Work  and  benefits  of  human  mainte- 
nance department,  81,  82 
Workroom,    cleanliness   of   and   purity 
of  air  in  prevention  of  industrial  poi- 
soning, 236 
Worry  among  employees,  30 
Wounds,    cleansing    of,    in    emergency 
surgery,  520 
closure  of,  in  emergency  surgery,  522, 

532 
drainage  of,  in  emergency  surgery,  521 
removal  of  foreign  bodies  from,   in 
emergency  surgery,  520 
Wrist  abduction  in  action,  559 
adduction  and  abduction  of,  558 
rotation,   flexion  and  extension  and 
lateral  movements  of,  559 

X-RAY  in  discovering  foci  of  infection 
about  teeth,  60,  63 
in  industrial  surgery,  568 

types  of  injury  requiring  exami- 
nation by,  569 
in  treatment  of  fractures,  598 
laboratory  of  medical  department,  41 
machine,  portable,  for  accident  sur- 
gery, 572 
room  in  doctor's  office,  568 

Y.  M.  C.  A.  in  connection  with  large 
industry,  103 

Zinc  ague,  218 

poisoning,  218 

skimmings,  health  hazards  in  distilla- 
tion of,  regulations  for,  257 

smelting,  health  hazard  regulations 
in,  269 


'4 


1^:. 


'*■       '         *-w 


COLUMBIA  UNIVERSITY  LIBRARIES 


0055756921 


'iJAHnW'Wi^ 


Demco,  Inc.  38-293 


